Victoria County Groundwater Conservation District 2805 N. Navarro St., Suite 210, Victoria, Texas 77901 Phone: (361)579 6863 FAX: (361)579 0041 Website: www.vcgcd.org Email: admin@vcgcd.org APPLICATION TO DRILL A WELL Complete this application for the purposes of obtaining a permit to drill a new water well or replace an existing water well. Note: In accordance with the District s rules, the District may request additional information not requested in this application in order to consider the application administratively complete. Note 2: Water wells to be used to produce groundwater for non-exempt use purposes require a production permit authorizing operation of the subject well. Note 3: Definition of Terms EXEMPT USE means the operation of a well, well field, or well system: 1. For the sole purpose of producing groundwater to be used for domestic use purposes; 2. For the sole purpose of providing groundwater for livestock, poultry or personal recreation that is drilled, completed, or equipped so that it is incapable of producing more than 28,800 gallons of groundwater per day; 3. For the sole purpose of providing groundwater for fire fighting; 4. For the sole purpose of providing a heat source or heat sink to a freshwater closed loop geothermal well; or 5. For the sole purpose of providing access to monitor groundwater resources that does not consume more than 5,000 gallons of water per year. EXEMPT USE WELL means a well utilized to produce groundwater to be used solely for exempt use purposes or a well otherwise exempt under the provisions of Section 36.117 of the Texas Water Code. NON-EXEMPT USE WELL means a well that is not an exempt use well. ADW Application to Drill a Well Page 1 of 5 Revision: 20170822
SECTION 1: LANDOWNER INFORMATION Landowner Name Mailing Address: City: State: Zipcode: Phone: E-Mail: Note: Documentation demonstrating ownership of the subject property such as appraisal district records or deed must be submitted with the application. SECTION 2: PROPOSED WELL LOCATION INFORMATION Property Address: City: State: Zipcode: Nearest Intersection: Latitude: Longitude: Is the proposed well site located within incorporated limits of a municipality? Specify the acreage of the proposed well site property: Note: a map of the well site that accurately describes the location of property lines at the perimeter of the well site and the location of each water well within the boundary of the well site is required. ADW Application to Drill a Well Page 2 of 5 Revision: 20170822
SECTION 3: INFORMATION RELATED TO PERMIT Question 1: Will the subject well be used solely for EXEMPT USE purposes or be otherwise exempt under the provisions of Section 36.117 of the Texas Water Code? Question 1a: If the answer to question 1 is NO, is the proposed well related to an existing production permit? N/A If YES, specify the production permit number: Question 2: What purpose will the groundwater produced from the subject well be put? (Examples. Domestic, Livestock, Commercial) Question 3: What is the intended capacity of the subject well in gallons per minute? GPM Question 4: Will the subject well be offset from wells owned by another person by a distance equal to one foot per one gallon per minute of the intended capacity as specified for Question 3? Note: if question 4 is answered NO, a waiver of the Question 5: Will the subject well be at least fifty (50) feet from the nearest property line? Note: if question 5 is answered NO, a waiver of the Question 6: Will the proposed well be at least 50 feet from any potential sources of contamination? Note: if question 6 is answered NO, a waiver of the ADW Application to Drill a Well Page 3 of 5 Revision: 20170822
Question 7: Will the subject well be located on a tract of land or lot of a platted subdivision with requirements related to water wells such as designating an authorized drilling area? Note: if question 7 is answered YES, relevant information such as a copy of the subdivision plat or deed covenants as filed with Victoria County will be required. Question 8: Is the proposed well a replacement well for an existing well that will be plugged and abandoned? Question 8a: If the answer to question 8 is YES, is the existing well registered with the District? N/A If YES, specify the well registration number: Note: If question 8a is answered NO, an Application to Register a Well for the existing well will be required. Question 9: Is a waiver or variance of any of the District s rules or requirement requested? Note: If question 9 is answered YES, additional information relevant to the waiver and good cause for granting the waiver will be required. Question 10: Is the District authorized to release any resulting permit to a person or entity other than the applicant? Note: If question 10 is answered YES, specify the contact information for the persons or entities that the resulting permit may be released: Question 11: Is the District authorized to register the subject well upon receipt of the related well driller s log? Note: If question 11 is answered NO, then well owner will be required to submit an Application to Register a Well for the subject well. ADW Application to Drill a Well Page 4 of 5 Revision: 20170822
SECTION 4: DESIGNATION OF AUTHORIZED AGENT The following individual is designated as an authorized agent for all matters regarding water well permitting, water well registration, and waiver requests for the subject property of this application. Name: Contact Information: SECTION 5: CERTIFICATION AND AGREEMENT I certify under penalty of law that this document and all attachments were prepared under my direction or supervision; the information submitted is, to the best of my knowledge and belief, true, accurate and complete; and I agree to operate the subject well in accordance with the Victoria County Groundwater Conservation District s Rules and the State of Texas regulations. Further, I certify under penalty of law that I am the landowner or I possess legal authorization to act as the agent of the landowner. Signature of Landowner or Authorized Agent Date Printed Name of Landowner or Authorized Agent ADW Application to Drill a Well Page 5 of 5 Revision: 20170822