Well Registration Request « Hays Trinity Groundwater Conservation District

This form provides notification of intent to drill, alter, or register a well or other aquifer penetration within the boundaries of the Hays Trinity Groundwater Conservation District.

A. WELL OWNER INFORMATION Any person who has the right to produce groundwater, either by ownership, contract, lease, easement, or any other estate in the land.

Business/Organization:

First Name:

*

Last Name:

*

Mailing Address:

*

City:

*

State & Zip:

*

Phone:

*

Alternate Phone:

Fax:

Email:

Is this well being installed as part of a near term real estate transaction? If so, the new owner must register the ownership change within 60 days of the transaction.

B. WELL LOCATION

Well Location Same as Section A Owner Address?

Address:

*

City:

*

State & Zip:

*

Latitude (Degrees, Minutes, Seconds)

Longitude (Degrees, Minutes, Seconds)

Elevation (in feet):

Provide specific directions to the location of the well on the property

C. PURPOSE OF WELL REGISTRATION

A well is any artificial penetration, excavation, borehole or other man-made feature constructed for the purposes of exploring for or producing groundwater, or for injection, monitoring, or de-watering purposes or a leachate or remediation well. Also includes a closed loop well. (e.g. geothermal systems, etc.)

* You must select one of the options below

Register an Existing Well
Any well in the District that was properly drilled and completed on or before September 1, 2001. (no fee)

Register a New Well or Alteration of a Well Any well that is not an existing well or any existing well that has been modified to increase water production after September 1, 2001. ($300.00)
Drill a New Well
Register an Existing New Well A well completed after September 1, 2001
Alteration or Modification of a Well After September 1, 2001 to increase production To change the physical or mechanical characteristics of a well, its equipment, or production capabilities. This does not include repair of well equipment, well houses or enclosures, or replacement with comparable equipment. A change in the purpose or location of use of the water produced is a modification.
Alteration to Plug a Well

If Alteration, explain reason for and production capability of modified well:

Anticipated Start Date of Drilling/Alteration:

D. WELL SPACING STANDARDS Any distances greater than 2,000 feet can be answered with “>2,000″.

How many feet is the well from the closest property line? (greater than 50ft?)	*
How many feet is the well from an existing well?	*
How many feet is the well from a concentrated source of potential contamination, such as livestock or poultry facilities? (greater than 150ft?)	*
How many feet is the well from a septic system drain field or wastewater irrigation system? (greater than 100ft?)	*
How many feet is the well from any septic tank? (greater than 50ft?)	*
Is the well located within 50 feet of or within the service area of a public water system? *	Yes No If yes, which system?

E. WELL DRILLER’S INFORMATION

Company Contracted

If driller is not in list, please complete the following information.

Company:

*

Address:

*

City:

*

State & Zip:

*

License Number:

*

Phone Number:

*

Fax Number:

*

Email:

F. PUMP INSTALLER’S INFORMATION

Same as Section E. Driller?

Company Contracted

If installer is not in list, please complete the following information.

Company:

*

Address:

*

City:

*

State & Zip:

*

License Number:

*

Phone Number:

*

Fax Number:

*

Email:

G. GENERAL WELL INFORMATION If this is a new well, please provide an estimate.

Casing Size (inches):	*
Well Depth (feet):	*
Pump Size (hp):	*
Production Capability (gpm):	*
Where will water from the well be used?

H. PURPOSE OF WELL Check all the apply.

Exempt Purpose Types

Residential / Domestic Well A well used solely for domestic use by a single private residential household and producing less than 25,000 gallons per day. The use of groundwater by an individual or a household, including a home-based business, including water for use inside the home; for irrigation of lawns, or of a family garden and/or orchard; for watering of domestic animals; for swimming pools associated with a single residence, for stock watering ponds of less than 1/4 acre extent with an average depth of less than 3-feet, that are lined with bentonite, geomembrane, or an equivalent sealing material as adjudged by the Distict.

Agricultural The use of groundwater for: (A) Cultivating the soil to produce crops for human food, animal feed, or planting seed or for the production of fibers; (B) Practicing floriculture, viticulture, silviculture, and horticulture, including the cultivation of plants in containers or non-soil media, by a nursery grower; (C) Raising, feeding, or keeping animals for breeding purposes or for the production of food or fiber, leather, pelts, or other tangible products having a commercial value; (D) Planting cover crops, including cover crops cultivated for transplantation, or leaving land idle for the purpose of participating in any governmental program or normal crop or livestock rotation procedure; (E) Engaging in wildlife management as defined in Texas Tax Code Section 23.51(7); and, (F) Raising or keeping equine animals.

GeoExchange Number of Wells

Non-Exempt Purpose Types

Irrigation Use of groundwater to supply water for application to plants or land in order to promote growth of plants, turf, or trees. Irrigation use for agricultural purposes and for residential purposes is exempt from obtaining an operating permit. All other irrigation use must obtain an operating permit.

Public Water System A system as defined by 30 Texas Administrative Code Section 290.38 for providing water to the public for human consumption.

Retail Public Water Utility As defined by 30 Texas Administrative Code Section 291.3, any person, corporation, public utility, water supply corporation, municipality, political subdivision or agency operating, maintaining, or controlling within the District facilities for providing potable water service for compensation.

Commercial The use of groundwater to supply water to properties or establishments that are in business to build, supply or sell products, or provide goods, services or repairs and that use water in those processes, or to supply water to the business establishment primarily for employee and customer conveniences (i.e. flushing of toilets, sanitary purposes, or limited landscape watering).

De-watering Well A well used for lowering the water table for construction purposes.

Industrial Use of groundwater primarily in the building, production, manufacturing, or alteration of a product or goods, or to wash, cleanse, cool, or heat such goods or products.

Injection Well A well used to inject water or other material into a subsurface formation or into pipe or tubing placed in the formation for the purpose of storage or disposal of the fluid.

Monitor Well A well generally used for collecting water-quality and/or water -level data on an ongoing basis.

Aquifer Test Well / Observation Well A well for observing water level changes during an aquifer test.

Aquifer Test Well / Pumping Well* The pumping well used during an aquifer test.*MUST COMPLETE AQUIFER TEST WELL PERMIT APPLICATION.

Remediation A well used to pump or vent contaminated air, water, or fluids from the ground.

Other Purpose Type

Other Exempt NonExempt

I. FEE

There is a $300 Well Construction Fee, if application is for a new well or the alteration of a well.

J. PREPARED BY

By signing this form, I declare that I have knowledge of the information provided in this form and that it is true and correct, to the best of my knowledge and belief. Furthermore, I am familiar with all pertinent requirements contained in the Hays Trinity Groundwater Conservation District Rules including the District's well construction standards. I agree to notify the District before the start of drilling/alteration and upon completion of the well. I understand that it is the Well Owner's responsibility to ensure that within 60 days after the completion of the well, the driller submits the State of Texas Well Report (Well Log) to the District. I agree to allow District representatives to enter the well site property to inspect during drilling and upon well completion.

I agree to the conditions.*

Well Owner or Authorized Agent Name
(First Last):

*

Contact Information (if different from Section A):

Address:

City:

State:

Phone Number:

K. COMMENTS

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