Application to Register a Well
Based on TGR Form #1(adopted 5/2003)
Form Updated 3/12/2004 (MTR)

Provide the Following Information:
* - Indicates Required Field

Contact Information
*Owner Name: *Telephone:
*Contact Person: Fax:
*Owner Mailing Address:
*City: *State:
*Zip Code:
Owner Email Address:
Physical (911) Well Location
(if different):
City: State:
Zip Code:
 
Well Information
Well Identifier:

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)

 
Please select "yes" or "no":
1. Will the well supply water to more than five households? Yes No
2. Will the well be on or serving a tract of land less than five acres? Yes No
3. Will water produced from the well be transported outside of the District's boundaries? Yes No
4. Do you have the State Well Drillers Report for the well Yes No
5. Is the well connected to an irrigation system? Yes No
If yes, how large is the area that is irrigated?
6. 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

Please answer all of the following to the best of your ability
State Well Number: PWS ID:
Edwards Aquifer Authority Well ID: SAWS Permit Number:
Well Location Longitude: Well Location Latitude:
Coordinate System Used(ie: USGS Map, GPS...)
Approximate Well Head Elevation: (ft)
Lot, Block, Subdivision:
Survey, Abtract, County Block: Acreage:
Well Information
Total Depth: (ft) Depth of Casing: (ft)
Casing Type: Casing Diameter: (in)
Depth To Pump: (ft) Pump Horse Power:
Cementing Method: Cemented to surface? Yes No
Completion Date: Target Formation:
Depth to Water: (ft) Date Measured:
Is the well drilled, completed, or equipped to produce more than 10,000 gallons per day(6.944 gpm)? Yes No
What is the Maximum Pumping Rate? GPM
Is the well metered? Yes No
If yes, what is a current meter reading and the date that it was taken? Reading:
Date Read: 		   Gallons
 

 
Well Driller Co.: Phone:
Well Driller State License Number:
Pump Installer Co.: Phone:
Pump Installer State License Number:
Additional Comments:



 
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