Notice of Intent to Drill or Modify a Well
Based on TGR Form #2(Adopted 5/2003) Rev. 1.5
 Form Updated 1/3/2006

* - indicates required field

Well Identifier:
 
Check Appropriate Selection:
New Well
Modification of Existing Well(Deepening Addition of Liner)
Plugging a Well


Please select "yes" or "no":
1. Will the well be drilled, completed, or equipped to produce more than 10,000 gallons per day(6.944 gpm)? Yes No
2. Will the well supply water to more than five households? Yes No
3. Will the well be on or serving a tract of land less than five acres? Yes No
4. Will water produced from the well be transported outside of the District's boundaries? Yes No
5. Do you have the State Well Drillers Report for the well? Yes No
6. Is the well connected to an irrigation system? Yes No
If yes, how large is the area that is irrigated?
7. Is water produced from the well discharged into a pond or impoundment, other than a swimming pool? Yes No
If yes, describe the pond or impoundment
8. Type of Sewer Disposal: Septic Sanitary Sewer

 
*Owner Name: *Telephone:
*Owner Mailing Address:
*City: *State:
*Zip Code:
Owner Email Address:


*Well Driller Co. *Phone
*Mailing Address
*City *State
*Zip
*Well Driller State License Number


*Pump Installer Company *Phone
*Mailing Address
*City *State
*Zip
*Pump Installer State License Number

*Well Location Longitude: *Well Location Latitude:
Coordinate System Used(ie: NAD 84, UTM...)
Approximate Well Head Elevation:
Lot, Block, Subdivision
Survey, Abtract, County Block Acreage

 
Physical (911) Well Location
(if different):
City: Zip Code:

 
Purpose of Well (Check ALL that apply)   Domestic (private homeowner well)  
Livestock Irrigation Industrial Agricultural
Municipal For Sale to Others Public Safety(specify)
Monitor Well Commercial Other(specify)

 
Proposed Well Charateristics
Total Depth: feet Depth of Casing:
Casing Type: Casing Diameter:
Cementing Method:
Target Formation:
How many gallons of water do you withdraw from the well on a daily basis?

Additional Comments:

*Signature of Owner or Representative:    
(Typing your name in this box will serve as your electronic signature.)
*Date:    

 

 
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