Spacing Exception Waiver

As provided in Panola County Groundwater Conservation District (“District”) Rule 5.3, any person that applies to the District to drill a new well may request an exception to the District’s water well spacing requirements in District Rule 5.2. Such a request must be accompanied by waivers signed by all landowners and well owners with property, existing wells or an approved well site that would be located closer to the applicant’s proposed well than what is provided by the spacing requirements in the District Rules.

Name of Applicant

has submitted/will submit a Drilling Permit application to the District requesting authorization to drill a new water well located at

Address / Approx. location of well

Well Name

PCGCD #

Longitude

Latitude

and requests the landowner's/well owner's approval of the following spacing exception(s):

1. Please Select One of the Following:

Exception to Spacing Requirement from Property Line

Exception to Spacing Requirement from Other Well Site

Exceptions to Both Spacing Requirements from Property Lines and Other Well Sites

2. List the Spacing Requirement(s) Under District Rule 5.2 and the Spacing Requested:

Casing Size *

From Property Line:

North

South

East

West

Spacing Required by Rules (Feet):

Spacing Requested by Applicant (Feet):

From Other Well Site:

Spacing Required by Rules (Feet):

Spacing Requested by Applicant (Feet):

Land / Well Owner Potentially Affected

By signing below, I acknowledge that the Applicant has requested the above-described exception(s) to the District's spacing requirements and as a landowner/water well owner potentially affected by the requested waiver, I hereby agree to waive any objection to the proposed location of the water well site.

Signature *

Clear

Date *

Well Name / PCGCD#

Print Name / Title *

Business / Organization Name (if applicable)

Address of Property / Well Location *

Latitude

Longitude

Submit