Office use only: □Approved □Denied Date and Initial:_________________
PLEASE NOTE: Any application that is not completed with reasonable diligence will not be accepted until all required information is provided. Water wells that are drilled, altered, and/or completed without PCGCD approval can be forcibly plugged by the PCGCD, and civil penalties up to $10,000 per day per violation can be charged to the water well owner, the water well driller, or both.

1. Well Use:

2. Applicant/ Property 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:

FEES: If this is an application to DRILL or ALTER a well, a $100.00 report deposit is required at the time of submittal. If the well report is timely submitted to the District, the District will return the well report deposit in full.
 
AFFIRMATION:
I certify that all statements and information in this application are true and correct. I also declare that all groundwater withdrawn will be put to beneficial use at all times, and that the applicant will abide by the Management Plan and Rules of the Panola County Groundwater Conservation District. It is further understood by the applicant that any obligation to notify the owners of the rights to the groundwater from this property of this production rests with the applicant.