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State of Washington, Department of Ecology <br />IAA No. C2600194 <br />Entity Name: Kittitas County Public Health Department <br />County Name: <br />Person reporting: <br />APPENDIX C <br />WELL CONSTRUCTION AND DECOMMISSIONING <br />QUARTERLY REPORT FORM <br />Contact phone number: <br />Contact email: <br />Year: <br />Quarter: ❑ JAN - MAR (due Apr 20th) ❑ APR - JUN (due July 20th) <br />❑ JUL - SEP (due Oct 20th) ❑ OCT - DEC (due Jan 20th) <br />Well Construction _ _ Number <br />Reports of new (and alteration of existing) wells <br />Number called -in county <br />New wells (and alteration of existing) inspected at least once <br />First inspection only <br />Total number of well inspections <br />Could be more than one inspection per well call -in <br />Wells inspected with driller present <br />Interaction with driller is encouraged <br />Planned well inspections with driller absent <br />T _ Well Decommissioning Number <br />Reports of new (and alteration of existing) wells <br />Number called -in county <br />New wells (and alteration of existing) inspected at least once <br />First inspection only <br />Total number of well inspections <br />Could be more than one inspection per well call -in <br />Wells inspected with driller present <br />Interaction with driller is encouraged <br />Planned well inspections with driller absent <br />Ecology Contact: Scott A. Malone <br />Well Construction and Licensing Coordinator <br />Phone (360) 407-6648 <br />Send completed form to: <br />Email: scma461@ecv.wa.R0v Mail: Department of Ecology <br />Well Construction Unit <br />PO Box 47600 <br />FAX (with cover sheet): (360) 407-7162 Olympia, WA 98504-7600 <br />ECY 070-529 (Revised 04/16)J To request ADA accommodation including materials in a format for the visually <br />impaired, call Ecology Water Resources Program at 360-407-6872. Persons with impaired hearing may call <br />Washington Relay Service at 711. Persons with speech disability may call Ti'Y at 877-833-6341. <br />12 <br />Version 1/5/2026 <br />