Drilling Permit Application Office use only: Application: □ approved □ denied Initial:________________________ Permit Number: O - __________ PCGCD Well Number:_____________ Permit Issued(date):_PLEASE NOTE: APPLICANT MAY SUBMIT OPERATING PERMIT APPLICATION IN CONJUNCTION WITH THIS DRILLING PERMIT APPLICATION TO STREAMLINE THE PROCESS.Qualifications to Apply for Drilling Permit: All new wells that are not exempt from the District’s permitting requirements must obtain a Drilling Permit from the District prior to the drilling or construction of the new well.Instructions: Fill out this form for each proposed well. Submit permit application form by mailing to the District’s mailing address or by faxing to the District to the fax number provided below. Additional information or explanation may be attached to this application form.NOTE - If submitting this application in conjunction with an Operating Permit Application, please note that you may submit one copy of the documents that are required to be submitted under Section 4 of this application form and Section 6 of the Operating Permit Application form and that you do not have to submit two copies of the same documents.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 the basis of, and 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. In addition, the information given in this permit application will be supplemented by the information provided by the permit applicant in the well registration form that is/was submitted to the District for the existing well.1. Applicant Information The Applicant for this Drilling Permit is the well: (please check all that apply) * Owner Operator Property Owner applicant name * First last * Last company name email * phone number * address * city * state * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY postal code * contact person (if different from applicant) * phone number * email address * owner of property where well is located * phone number * email address * 2. Legal Description: (please provide attachments if available) survey name * abstract number * longitude * 3. Well Information Quantity of water to be produced by this well annually (please specify in acre-feet or gallons): * Nature and purpose for which water produced from well will be used: * If multiple purposes of use, please indicate the amount of water that is used for each purpose: Location of use of the water produced from the well: * Estimated rate at which water will be withdrawn from well: * Maximum pumping capacity of the well (in gallons per minute): * Method of withdrawal from well/type of pump: * Turbine Submersible Windmill Other (please specify) Depth of well: * Size of well pump: * Size of well (inside diameter of the column pipe and diameter of the well casing): * Duration of time water is expected to be put to beneficial use under the permit: * Temporary/short-term use Seasonal use Continual use Will the groundwater withdrawn from the well be resold, leased, or otherwise transferred to others? * Yes No If YES, please provide the location to which the groundwater will be delivered: Purpose of use: * 4. Required Documentation/Attachments to this Application:A. If the well owner/operator is different than the owner of the property on which the well is located, attach documentation establishing the authority to operate the well for the proposed use;B. A location map showing the proposed well location and, if applicable, an alternative well location meeting the District’s minimum spacing and location requirements, and showing all wells in existence within a quarter (1/4) mile radius of the location of the well. (If possible, please provide location map on a 7.5 minute United States Department of Interior Topographic Map and/or provide the latitude and longitude coordinates of the well location as measured by a calibrated GPS instrument);C. If available, a legal description, such as survey information, maps, and/or metes and bounds descriptions, of the tract of land on which the well or well system is located;D. A drought contingency plan if the applicant is required to prepare a drought contingency plan by other law;E. If water is to be sold, leased, or transferred to others, whether inside or outside the District, attach legal documents establishing the right for the water to be sold, leased, or transferred, including but not limited to any contract for the sale, lease, or transfer of water;F. If water is to be transferred outside the boundaries of the District (Panola County), please provide explanation and documentation relevant to the following: (1) availability of water in the District and in the proposed receiving area during the period for which the water supply is requested; (2) projected effect of the proposed transport on aquifer conditions, depletion, subsidence, or effects on existing permit holders or other groundwater users within the District; and (3) how the proposed transport is consistent with the approved regional water plan and certified district management plan; andG. Proof that notice was sent by certified mail, return receipt requested, to all property and all well owners of existing registered or permitted wells within 1/4 mile radius of the well(s) that is the subject of the application and a separate list of the names and addresses of the property owners to that were notified by certified mail. Notice provided to property and well owners must meet the requirements in District Rule 3.9(e). Please note that you may combine notice for a Drilling Permit Application and an Operating Permit Application if you submit both applications at the same time. Click here for a downloadable sample notice.H. A water conservation plan or accept/decline here as a declaration that the applicant will comply with the District’s Management Plan: H. A water conservation plan or sign here as a declaration that the applicant will comply with the District’s Management Plan: * I accept. I decline. FEES: 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.I hereby swear or certify that the information in this permit application is true and accurate to the best of my knowledge and belief. Signature * signature keyboard Clear Date * reCAPTCHA If you are human, leave this field blank.
