Transfer of Ownership Application I PCGCD

PLEASE TAKE NOTE: If the land owner wishes to keep the rig water supply well for a beneficial use, the following actions must take place before the transfer of the well can be completed:

1.) The pump must be removed from the well casing;

2.) The District must be notified in writing with a Transfer of Registered Well Request Form that the land owner desires to take control of the water well;

3.) The District will inspect the well for structural damage to the casing or screen and any indications of commingling of aquifers or zones;

4.) A fee of $200.00 at the time of the inspection is required.

If the well does not pass inspection, the District will not approve the transfer and will require that the water well be plugged at that time.

1. Applicant and Transfer Information

The Applicant for this Transfer is the CURRENT Well: (please check all that apply) *

Owner

Operator

Property Owner

Name of Current Registered Well Owner *

First

Last

Street / P.O. Box *

City *

State *

Postal Code *

Phone *

Alternate Phone

Name of Property Owner Assuming Ownership *

First

Last

Street / P.O. Box *

City *

State *

Postal Code *

Phone *

Alternate Phone

Fax

2. Location

Please Give an Address and Physical Location of the Well (i.e. 25 feet west of house) *

3. Legal Description

Survey Name *

Abstract Number *

Latitude *

Longitude *

5. Well Information

Number of Acres in the Tract in Which This Well Is Located *

Quantity of Water to Be Produced by This Well Annually (specify in acre-feet or gallons) *

Nature and Purpose for Which Water Produced from Well Will Be Used *

If Multiple Purposes of Use, Please Indicate the Amount of Water That Is Used for Each Purpose

Location of Use of the Water Produced from the Well *

Estimated Rate at Which Water Will Be Withdrawn from Well *

Maximum Pumping Capacity of the Well (in Gallons per Minute) *

Method of Withdrawal from Well / Type of Pump *

Turbine

Submersive

Windmill

Other

Depth of Well *

Size of Well Pump *

Size of Well (Inside Diameter of Column Pipe and Diameter of Well Casing) *

Will the Groundwater Withdrawn from the Well Be Resold, Leased, or Otherwise Transferred to Others? *

Yes

If YES, Please Provide the Location to Which the Groundwater Will Be Delivered *

Signature

Signature of Property Owner Assuming Ownership *

Clear

Date

Submit