Water Well Application

1. Application Type

Purpose of Application *

Drill a New Well

Drill a Replacement Well

Plugging a Well

Operate/Register an Existing Well

Alter an Existing Well

Operating Permit

Permit Renewal

Permit Amendment

Export Permit

2. Applicant / Well Owner

Well Owner Name *

First

Last

Email Address

Phone Number *

Address *

City *

State *

Postal Code *

Contact Person

Phone Number

Email Address

3. Well Driller

Drilling Company Name *

Driller Name *

First

Last

Address *

City *

State *

Postal Code *

Email Address

Phone Number *

TX Water Well Driller License # *

Pump Installer Name *

First

Last

Phone Number

TX Water Well Pump Installer License # *

4. Water Well Location

Please provide specific directions to water well site and a physical address where water well is located. Attach a copy of the property plat or some type of map with the well site accurately located. Deed or other proof of ownership may be required. *

Latitude (NAD_ 1983) *

Longitude (NAD_1983) *

Survey Name

Total Acreage of Property *

According to Rule 3.4(d) of the District Rules, all new wells must be drilled within 30 feet (10 yards) of the location specified in the registration or permit application.

5. Water Well Specifics

Is/Will This Well Be Used for More Than One Household? *

Yes

If Yes, How Many Households?

Will/Is the Well Connected to a Crop Irrigation System? *

Yes

If Yes, How Large of an Area Is Irrigated?

Will/Is the Water from This Well Discharged Into a Pond or Impoundment or Used for Hydraulic Fracturing? *

Yes

Will/Is the Water from This Well to Be Used in Conjunction with Other Water Wells Within a ¼ Mile Radius? If Yes, Please List Below. *

Yes

Well Name #1

Latitude

Longitude

GPM

Well Name #2

Latitude

Longitude

GPM

Well Name #3

Latitude

Longitude

GPM

7. Well Use Data

Duration of Time That Water Is Expected to Be Put to Beneficial Use Under This Permit:

Temporary/Short-Term

Seasonal

Continual

Quantity of Water to Be Produced by This Well Annually (in Gallons):

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

Will the Water Withdrawn Under This Permit Be Put to Beneficial Use at All Times:

Yes

Is the Applicant a Retail Public Utility as Defined by Section 13.002 of the Texas Water Code? Y/N

If YES, List Subdivision(s), CCN Service Area, or the Governmental Entity Boundaries That the Existing Well Will Service:

Will the Groundwater Withdrawn Under This Permit Be Used in Conjunction with Another Operating or Grandfathered Use Permit? Y/N If Yes, Explain:

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

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

Check the Box to Acknowledge Submission/Compliance with the Following Statements: (This Must Be Checked and Fees Paid for an Application to Be Deemed Administratively Complete.)

Acknowledge

Permit Acknowledgements

____A. If the well owner/operator is different than the owner of the property on which the well is located, attach documentation establishing the authority to operate the well for the proposed use;
____B. A location map showing the proposed well location and, if applicable, an alternative well location meeting the District's minimum spacing and location requirements, and showing all wells in existence within a quarter (1/4) mile radius of the location of the well. (If possible, please provide location map on a 7.5 minute United States Department of Interior Topographic Map and/or provide the latitude and longitude coordinates of the well location as measured by a calibrated GPS instrument);
____C. If available, a legal description, such as survey information, maps, and/or metes and bounds descriptions, of the tract of land on which the well or well system is located;
____ D. A water conservation plan or sign here as a declaration that the applicant will comply with the District's Management Plan: ________________________________________ (Applicant's Signature);
____E. A drought contingency plan if the applicant is required to prepare a drought contingency plan by other law;
____F. If water is to be sold, leased, or transferred to others, whether inside or outside the District, attach legal documents establishing the right for the water to be sold, leased, or transferred, including but not limited to any contract for the sale, lease, or transfer of water;
____G. If water is to be transferred outside the boundaries of the District (Panola County), please provide explanation and documentation relevant to the following: (1) availability of water in the District and in the proposed receiving area during the period for which the water supply is requested; (2) projected effect of the proposed transport on aquifer conditions, depletion, subsidence, or effects on existing permit holders or other groundwater users within the District; and (3) how the proposed transport is consistent with the approved regional water plan and certified district management plan;
_____H. Applicant will comply with the District's Rules and all groundwater use permits and plans pursuant to District's Rules;
_____I. Applicant will comply with all District well plugging and capping guidelines and report closure to the District and the appropriate state agencies; and
_____J. The District shall provide the applicant with notices to be provided by the applicant to all property owners and all well owners of existing registered or permitted wells within 1/4 mile radius of the well(s) that are the subject of the application. The applicant shall provide certificates of mailing to the District to document notifications were mailed. Notice provided to property and well owners must meet the requirements in District Rule 3.9(c). Please note that you may provide one notice for a Drilling Permit Application and an Operating Permit Application at the same time by attaching this application.
_____K. Applicant will comply with any production reductions imposed by the District in response to drought conditions and/or to achieve the desired future conditions of the aquifer. __________________________(Applicant's Signature)
_____L. All wells that are capable of producing groundwater at the rate of one hundred and fifty (150) gallons per minute or higher must have a baseline water quality test completed at the well owner's expense.

Declaration That the Applicant Will Comply with the District's Management Plan (Applicant's Signature)

Applicant Will Comply with Any Production Reductions Imposed by the District in Response to Drought Conditions and/or to Achieve the Desired Future Conditions of the Aquifer. (Applicant's Signature)

Plugging Method

Plugging Method – Please Describe the Method if This Is a Plugging Application.

DEPOSIT: For all Drilling and Plugging Applications a $100.00 report deposit is required from the driller at the time of submittal. If the well report or plugging report is timely submitted to the District, the District will return the report deposit in full.

AFFIRMATION: I certify that, as the Applicant, I am the owner of the well which is the subject of this Application, or the Authorized Agent of the well owner. Additionally, I certify that each and all of the statements and information contained herein are true and correct to the best of my knowledge and belief. Moreover, I agree to fully comply with the terms of the Panola County Groundwater Conservation District's enabling legislation, the rules of the District, and any water well plugging application requirement that may be requested pursuant to this Application. I understand that failure to comply with the rules of the District and failure to properly plug the water well that is the subject of this Application can result in enforcement by the District.

Signature of Owner/Agent *

Clear

Signature of Driller *

Clear

Submit

Water Well Application

1. Application Type

Purpose of Application *

2. Applicant / Well Owner

Well Owner Name *

3. Well Driller

Driller Name *

Pump Installer Name *

4. Water Well Location

5. Water Well Specifics

6. Well Data

Please Check Only One. *

7. Well Use Data

Plugging Method