Office use only: □Approved □Denied Date and Initial:_________________
PLEASE NOTE: Any application that is incomplete will not be deemed administratively complete and processed by PCGCD until all required information is provided. Water wells that are drilled, altered, completed and/or operated without PCGCD approval can be forcibly plugged by PCGCD, and civil penalties up to $10,000 per day per violation can be charged to the water well owner, water well driller, or both. All administratively incomplete applications will expire if not completed in 90 days from the day the District requests information or clarification or upon conclusion of an extension granted by the General Manager of the District.

FOR PERMIT APPLICANTS: In accordance with District Rule 3.7(e), the information provided by the permit
applicant in the spaces below will be incorporated into the permit if a permit is issued by the District. The permit will be granted on a two (2) year basis or five (5) year basis for grandfathered permits and is contingent upon the accuracy of the information supplied in this application. A finding that false information has been supplied is grounds to refuse or deny the application or for immediate revocation of the permit.

METERING REQUIREMENTS: As required by District Rule 6.1(a) (1-3) the following wells shall be equipped
with a meter or a flow measurement device: (1) All new, non-exempt wells; (2) existing wells that have been
substantially altered to become non-exempt; (3) a well which produces water that is sold or leased to another person or entity; (4) a well used to supply water for active oil & gas drilling or exploration operations; (5) a well authorized under permit issued by the Railroad Commission of Texas under Chapter 134 for mining activities; (6) monitor wells; (7) remediation wells and (8) aquifer storage and recovery wells. The meter shall operate on the well to measure the flow rate and cumulative amount of groundwater withdrawn from the well to be submitted quarterly to PCGCD.

PLUGGING REQUIREMENTS: No water well plugging can commence until the application has been processed and written approval has been provided. Once approval is provided, the District must be notified at least 24 hours prior to initiation of the plugging operation by phone, email, regular mail, fax, or in person.

1. Application Type

2. Applicant/ Well Owner:

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3. Well Driller:

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4. Water Well Location:

According to Rule 3.4(d) of the District Rules, all new wells must be drilled within 30 feet (10 yards) of the location specified in the registration or permit application.

5. Water Well Specifics:

6. Well Data:

*Note that wells equipped to produce 200 gallons per minute or more must provide a Hydrogeological Report meeting the requirements of District Rule 3.17. Applicants required to complete a Hydrogeological Report must publish notice in the newspaper in accordance with District Rule 3.17(c).
If applying for a permit, please fill out the rest of the application, sign, and submit. If not applying for a permit, skip to the end, sign, and submit.
Duration of time that water is expected to be put to beneficial use under this permit:
Will the water withdrawn under this permit be put to beneficial use at all times:
Check the box to acknowledge submission/compliance with the following statements: (This must be checked and fees paid for an application to be deemed administratively complete.)
DEPOSIT: For all Drilling and Plugging Applications a $100.00 report deposit is required from the driller at the time of submittal. If the well report or plugging report is timely submitted to the District, the District will return the report deposit in full.

AFFIRMATION:
I certify that, as the Applicant, I am the owner of the well which is the subject of this Application, or the Authorized Agent of the well owner. Additionally, I certify that each and all of the statements and information contained herein are true and correct to the best of my knowledge and belief. Moreover, I agree to fully comply with the terms of the Panola County Groundwater Conservation District’s enabling legislation, the rules of the District, and any water well plugging application requirement that
may be requested pursuant to this Application. I understand that failure to comply with the rules of the District and failure to properly plug the water well that is the subject of this Application can result in enforcement by the District.