PECAN VALLEY GROUNDWATER CONSERVATION DISTRICT

P.O. Box 88, Cuero, TX 77954 361-275-8188 Fax: 275-9635

EXISTING WELL REGISTRATION

(PVGCD Office Use)

Registration # ___G -_ __ ___ Date ____________TWDB Grid # _____ __

Complete all questions to the best of your knowledge

Part I – Owner Information:

Property Owner:

Mailing Address: ( )

Street City Zip Phone Number(s)

Registrant: (if other than owner)

Mailing Address: ( )

Street City Zip Phone Number(s)

Part II - Well Location: (Directions to well site from nearest State or Federal Highway, or County Rd.)

Part III – Purpose for Water Use: (Mark (x) in all appropriate areas)

Public Supply Single-family dwelling (includes lawn irrigation)

Industrial Multi-family dwelling

Irrigation Livestock Tank Troughs

Other

Use: Amount Used: gallons/day

Use: Amount Used: gallons/day

Use: Amount Used: gallons/day

Have any water rights of the property for this well been leased, sold or transferred? (yes) (no)

Part IV – Well Information:

Estimated Maximum pumping capacity of well: gpm. Estimated depth of well: ft.

Inside diameter of the pump discharge pipe: Inside Diameter of Casing:

Well Coordinates: Latitude N Longitude W

Circle One: Pump Windmill Submersible Horsepower

Drillers Well Log: (yes) (no) If yes, please attach well log to this registration form

Signature of person preparing this form