ARW - APPLICATION TO REGISTER A WELL

Victoria County Groundwater Conservation District

P.O. Box 69, Victoria, Texas 77902
Phone: (361) 579-6863 | Email: admin@vcgcd.org | Website: www.vcgcd.org

APPLICATION TO REGISTER A WELL

Submit this application register or update the registration of an existing well.

Is this application associated with a well located with Victoria County, Texas*

YESNO

Error: This form should only be used to registered or update the registration of a well located within Victoria County, Texas.

Item 1: Specify the name and mailing address of the applicant:

Item 2: Specify the name and mailing address of the person that owns the subject well:

Item 3: Specify the geographic coordinate of the subject well:

Item 4: Specify the date the subject well was constructed:

Item 5: Specify the purpose of use of the produced groundwater from the subject well:

Item 6: Specify the maximum production rate of the subject well expressed in gallons-per-minute:

Item 7: Specify the name and mailing address of the individual or entity authorized to serve as the legal agent of the well owner regarding all matters related to physical access of the subject water well:

Item 8: Specify the name and mailing address of the individual or entity authorized to serve as the legal agent of the well owner regarding all matters related to submittal of reports associated with the subject water well:

Item 9: Specify the name and mailing address of the individual or entity authorized to serve as the legal agent of the well owner regarding all matters related to permitting matters associated with the subject water well:

Item 10: Required Statements and Signature of the Applicant:

I certify, under penalty of law, that the well owner possesses the legal authority to produce groundwater resources from the subject well; and I certify, under penalty of law, that the information reported on and attached to the application was prepared under the direction or supervision of the applicant and is, to the best of the knowledge and belief of the applicant, true, accurate and complete; and I certify, under penalty of law, that the subject well shall be operated in accordance with the rules of the district and regulations of the State of Texas.

Signature of Applicant

Date

Printed Name of Signee:

First NameLast Name

Optional: Enter an email address to receive a confirmation email and an electronic copy of the report for your records.

example@example.com

Note 1: The applicant is encouraged to attach any written waivers obtained from other landowners or owners of groundwater resources in connection with drilling of the subject well to this application.

Note 2: The district may request additional information not requested in this application in order to evaluate the request relative to the rules of the district.

Note 3: The applicant is encouraged to attach the driller's log for the subject well.

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