Office Use Only
Registration Number .
Uvalde County Underground Water
Conservation District
200 E. Nopal, Suite 203
P O Box 1419 Uvalde, TX 78802
830.278.8242 830.278.1904 FAX
NON-EXEMPT WELL REGISTRATION
Registration of (check one):
New Well Replacement Well Currently In Use Out of Service .
Well Ownership:
A. Name of Well Owner (Fee owner of land) ______
Address______Phone ______
B. Name of Person to Contact if different from owner: ______
Address: ______Phone ______
Well Location:
A. Well is or is to be located approximately ______miles ______(N, S, NW, etc.) of
______(Nearest Town).
B. Land surface elevation above sea level ______
C. Is well closer than (1) 50 feet to any water-tight sewage facility? Yes ____No ____
(2) 150 feet to any concentrated source of potential well contamination (Privy, Livestock yard, Underground Storage Tank, Septic System Absorption field, etc.)? Yes___ No ___
(3) 500 feet to any sewage treatment facility or solid waste disposal site? Yes___ No___
ATTACH A MAP SHOWING LOCATION OF WELL.
(Available online at www.uvaldecountyuwcd.org or District Office)
Source of Water: (Circle One): Austin Chalk, Leona Gravel, Trinity, Glen Rose, Buda Limestone,
Alluvium, other (specify): ______
Well Use:
A. (Circle One): Irrigation______Industrial______Public Supply ______Reaction______
B. Are there other wells in use with this well for the same operation? Yes _____ No _____
Well Date and Equipment:
A. Owner’s Well Number______
B. Driller______License No. ______Phone______
Address______Year drilled/to be drilled: ______
C. Total Depth ______D. Depth of Casing ______
E. Inside Diameter of Casing ______F. Type ______
G. Fuel or Power: Electric ______Diesel ______ other (specify) ______
H. Yield of Well:______gallons per minute. Estimated/Metered/Tested (Circle One)
I. If irrigation, amount of acreage ______
J. Type of Irrigation System ______
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Exceptions to Spacing/Production Rules
If the proposed well is to be frilled, completed and equipped such that it will require an exception to the spacing and production rule, attach a list of the names and addresses of all property owners adjoining the tract on which the well is to be located, within one-half mile. Also, fill out a Spacing Rule Exemption Form (found at www.uvaldecountyuwcd.org or District Office). Provide the names of owners of the three nearest wells within one half mile of the proposed location. Attach a map showing the property lines in the immediate area and show accurately to scale the location of the three nearest wells within one half mile of the proposed well location.
Applicant’s Certification – Please read CAREFULLY
A. I agree that this well will be drilled only in the formation (no dual completion wells are allowed) and size specified, and within thirty feet of the proposed location specified, and that any changes in these specifications will require an amendment to the Application and may require new Notice to the Public.
B. I will furnish the District the completed Well Registration form and Driller’s Log, and any mechanical log that might be made, within 60 days of completion of this well, or forfeit my deposit.
C. I understand that if this application, if approved, will have a term of up to 4 months, after which it shall be void and the deposit forfeited, unless extended upon written application to the Board.
D. Should the well be determined to be incapable of beneficial use as defined by the Rules of the District, the well shall be capped or plugged as specified in Rule 18 and/or Rule 19 and the application amended for any new well site. A Plugging Notice Form may be picked up online or at the District Office.
E. Estimated information or information not available at the time this application was filed will be corrected or provided when the well is registered with the District and prior to operating the well.
F. I understand that if this application is subject to the District Rules and any violations may result in deposit forfeiture and/or fines.
G. I certify that all the information provided in and with this application is true and correct to the best of my knowledge.
______
Signature of Well Owner/Agent (Circle One) Date
State of Texas
County of ______
Before me, a notary public, on this ______day of ______personally appeared ______, known to me to be this person whose name is subscribed to the foregoing document and , being by me first duly sworn, declared that the statements therein contained are true and correct.
______
Notary Public in and for the State of Texas
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APPROVAL
OFFICE USE ONLY
Attach Blank Form with Application.
Application Administratively Complete ______, 20______
______
Signature and Title
APPLICATION APPROVED ______, 20______
______
Signature and Title
This approved applications hall serve as a permit to drill a new well, or re-equip or replace an existing well, subject to the rule of the Uvalde County Underground Water Conservation District.
This application will remain valid until ______, 20______, unless application for an extension is made prior to this date.
This is not an Operating Permit. A Water Well Permit will be issued upon the District’s receipt of the following:
1. Completed Well Registration for
2. Driller’s Log
Application Fee Received: $50.00 Check Number ______Cash ____
Deposit Received: $100.00 Check Number ______Cash ______
Deposit Refunded: Date: ______Check Number ______
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