[PDF] Part I - Multi-purpose Form of Intent to Drill, Alter - PGCD



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Part I - Multi-purpose Form of Intent to Drill, Alter - PGCD

Abide by them By signing this form, the Well/ Penetration Owner understands that this allows PGCD to enter the property to inspect Signature of Well/ Penetration Owner/Date: Signature of Well Driller/ Date: Signature of Pump Installer/ Date: Form MP1 (Rev 04-10-15)



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A. Check appropriate box for type of application/ registration [ ] New Well: casing size____________________________ pump type and size__________________________________________ [ ] New Other Aquifer Penetration (fill out pertinent info) [ ] Alteration of Existing Well. Explain reason for and nature of alter ation: [ ] Alteration of Existing Other aquifer Penetration. Explain reason fo r and nature of alteration: [ ] Existing Well (apply for permit of existing well or register exist ing well) ___________ gallons per minute estimated capacity of requested well or alteration of existing well.

C. Anticipated Start Date of Drilling:

Well driller must notify PGCD 24 h before the following begin: [ ] Start of drilling [ ] Start of cementing [ ] Completion of we ll/penetration

PLEASE PRINT OR TYPE REQUESTED INFORMATION

For District Use Only

[ ] Well Permit

Expiration Date

(120 days)_______ [ ] Other Aquifer Penetration Registration _________________ [ ] Fee Paid $_________ [ ] Well Registration

Completion Paperwork Turned in:

[ ] State of Texas Well Drillers Report [ ] State of Texas Well Plugging Report (if applicable) [ ] State of Texas Report of Undesirable Water or Constituents (if applicable) [ ] Copies of all well information available (drillers log, etc.)

Pineywoods Groundwater Conservation District

District Mailing Address: P. O. Box 635187 Nacogdoches, TX

75963-5187 District Telephone Number: (936)568-9292

fax: (936) 568-9296

D. Please check one of the following: [ ] Capable of more than 25,000 gallons per day (17.36 gpm). If check

ed, please fill out Part I and II. [ ] Less than or equal to 25,000 gallons per day (17.36 gpm). If chec ked, please fill out Part I. Omit Part II.H. Well Driller Company Contracted With:

Part I - Multi-purpose Form of Intent

to Drill, Alter, or Register a Well or Other Aquifer Penetration

B. Additional Required Information:

1.Attach a copy of the deed record (page containing ownership

information as filed with the County Clerk).

2. Include a copy of the survey, plat, or on-site sewage facility

design plan of the property showing the location of the well and septic system (note distances).

3.Flood Plain Development Permit No:_____________

4.Submit the State Well Drillers Report (after complete)

If existing well, Name of Original Owner: E. Well/ Penetration Owner Information-Owner Name: F. Owner Tel:

G. Owner Mailing Address: Street or PO Box, City State Zip

J. Company Mailing Address: (Street or PO Box, City, State, Zip)K. Company Mailing Address: (Street or PO Box, City, State, Zip)

I. Pump Installer Company Contracted With: O. Company Fax / Email: N. Company Tel: M. Company Fax / Email: L. Company Tel:

P. Well Driller Name: Q. Pump Installer Name:

T. Well / Penetration Information-Latitude:

R. Weller Texas State License No. S. Pump Installer Texas State License No.

U. Longitude:

X. Unit AA. Block W. Name of Subdivision

V. Well / Penetration Site Physical (911) Location (Street Address, City, Zip) BB. Lot CC. If not located within a subdivision: Name and number of Survey/ Abst ract: DD. Acreage: EE. If no physical (911) or other address information, give directions on separate page to the property that will allow an inspector to find the site.

FF. Purpose of use (check all that apply): [ ] Domestic (private homeowner well) [ ] More than 10 households

[ ] Livestock [ ] Irrigation [ ] Industrial [ ] Municipal [ ] For Sale to others [ ] Public Safety [ ] Commerci al (give company name) [ ] Test well [ ] Monitor well [ ] Observation wel l [ ] Other (please specify): [ ] Hydrocarbon Exp loration GG. Distance of well/ penetration from septic tank and drain, leach, or absorption field (feet):

Distance from nearest property line (feet):

Distance from nearest building (feet)

Distance from centerline of nearest public road (feet):

Distance from existing well (feet): HH. By signing this form, you declare that you are familiar with the Dis

trict's current rules and well construction standards and agree to Abide by them. By signing this form, the Well/ Penetration Owner underst ands that this allows PGCD to enter the property to inspect.

Signature of Well/ Penetration Owner/Date: Signature of Well Driller/ Date: Signature of Pump Installer/ Date:

Form MP1 (Rev. 04-10-15)

Please fill out all necessary information prior to submission, be sure payment of fee is included

Part II - Application for Well Permit

Pineywoods Groundwater Conservation District For District Use Only Applies to wells capable of producing more than 25,000 gallons per day ( 17.36

Gallons Per Minu

te).

A. Owner Name, Address, and Phone no:

C. Location of Adjacent Permitted Wells. With assistance from the District, attach a map or plat drawn on a sca

le that adequately identifies all permitted wells within a one-mile radius of the proposed or existing wel l.

B. Location and Use of Produced Water: Attach a map or plat drawn on a scale that adequately details (and show

exact boundaries of property) the location of: [ ] Existing or proposed well and other improvements on the property Land surface elevation, mean sea level (ft):__________ __ [ ] Existing water use facilities

Geologic formation(s) from

which water is to be produced: [ ] Proposed use or increased use of produced water.

Permit No.

H. Availability of other water resources. Identify, if available, any other presently owned sources of water (i.e

., surface, treated) or those which could be owned or otherwise acquired, the availability of which is both technically feasible and economically reasonable for the permittee, that could be reasonably used for the stated purposes, including quality and quanti ty of such alternate sources:

I . Water Conservation Plans. Attach information showing what water conservation plan or measures the

permittee has adopted, what water conservation goals the permittee has established, and what measures and time frames are necessary to achieve the permittee's established wate r conservation goals.

Date Signed:

Date Application Completed:

Hearing Date:

Date Approved: Date Denied:

Permitted Use:

Permitted Capacity (gpy or Ac-Ft/Y):

Renewal Date:

D. Actual or anticipated annual amount of water to be used ( specify un its, gallons per year, acre feet per year): E. Actual or anticipated pump size in gallons per minute: F. Anticipated date the proposed construction or alteration is to begin:

G. Other:

J. Service area description of resold water: If the water is to be resold to others, attach a description of (check of attachments) [ ] service area population [ ] metering [ ] lead and repair program [ ] Is this a platted development [ ] yes [ ] no [ ] delivery and distribution system including number of connections K. Well driller must notify PGCD 24 hours before the following actions b egin [ ] Start of drilling [ ] Start of cementing [ ] Completion of well [ ] info on customer's water demands (per capita water use) [ ] water use data [ ] wastewater data [ ] water conservation measures [ ] water conservation and drought or emergency water management plan identifying trigger conditions and means of implementation and en- forcement L. After drilling and well completion, provide all the following well in formation, if available [ ] State of Texas Well Drillers Report [ ] Chemi cal Analysis [ ] State of Texas Well Plugging Report (if applicable) [ ] Geophysical Log [ ] Pump Test Data [ ] State of Texas Report of Undesirable Water of Cons tituents [ ] Hydrologic Analysis (if required) (if applicable) [ ] other (please specify):

Form MP1 (Rev. 04-10-15)

This form, when completed and approved by the District, is a Drilling Pe rmit. This permit will remain in effect for 120 days.quotesdbs_dbs13.pdfusesText_19