Transfer of Ownership Application

PLEASE TAKE NOTE: If the land owner wishes to keep the rig water supply well for a beneficial use, the following actions must take place before the transfer of the well can be completed:

1.) The pump must be removed from the well casing;
2.) The District must be notified in writing with a Transfer of Registered Well Request Form that the land owner desires to take control of the water well;
3.) The District will inspect the well for structural damage to the casing or screen and any indications of commingling of aquifers or zones;
4.) A fee of $200.00 at the time of the inspection is required.

If the well does not pass inspection, the District will not approve the transfer and will require that the water well be plugged at that time.

1. Applicant and Transfer Information:

The Applicant for this Transfer is the CURRENT well: (please check all that apply) *

owner

operator

property owner

Name of Current Registered Well Owner: *

first

last name *

last

street/ p.o. box *

city *

state *

postal code *

phone *

alternate phone

email

Name of Property Owner Assuming Ownership *

first

last name *

last

street/ p.o. box *

city *

state *

postal code *

phone *

alternate phone

fax

email

2. Location:

Please give an address and physical location of the well (i.e. 25 feet west of house) *

3. Legal Description:

survey name *

abstract number *

latitude *

longitude *

5. Well Information:

number of acres in the tract in which this well is located *

quantity of water to be produced by this well annually (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estimated rate at which water will be withdrawn from well *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

submersive

windmill

other

depth of well *

size of well pump *

size of well (inside diameter of column pipe and diameter of well casing) *

Will the groundwater withdrawn from the well be resold, leased, or otherwise transferred to others? *

Yes

No

6. Required Documentation/Attachments to this Application and Possible Fee:

The following documentation, attachments, must accompany this application in order for the application to be considered administratively complete:
A. Written notification from current well owner for a request to transfer ownership.
B. Original State Well Report.
C. Well Inspection Fee.
D. 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;
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;
G. If necessary, an Application for Operating Permit and any permit fees that may be required.

7. Certification of Requestor:

I hereby swear or certify that the information in this transfer request is true and accurate to the best of my knowledge and belief.

Signature of Current Owner or Agent *

Clear

date *

For PCGCD Office Use ONLY:
Date Received:__________________________ Date Inspected:____________________________
Inspected By:___________________________ DVD number:_____________________________
Does the inspection match the casing, blank pipe and screen data as provided on the State of Texas Well Report? Y N
State of Texas Well Report tracking number:_______________________________
Comments/Notes:____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Transfer Request Approved (date)_______________By:______________________________________________________
Transfer Request Denied (date)_________________By:______________________________________________________

Signature of Property Owner Assuming Ownership *