1. One application is required for each water well to be plugged.
2. This application must be completed, signed, and submitted to the Panola County Groundwater Conservation District prior to plugging any water well located within Panola County.
3. The application must be typed or printed legibly using ink.
4. Incomplete applications will be returned to the applicant for completion.
5. No water well plugging can commence until the application has been processed and written approval has been provided.
6. Once written approval has been provided, the Panola County Groundwater Conservation 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. Applicant/ Owner Information
First
Last
2. Well Site Information and Proof of Ownership
* Please provide proof of ownership (i.e., complete recorded deed or a current appraisal district record) with a legal description of the property and/or authority to plug the water well (Property owners that sign below do not need to provide authority to plug).

** Please provide a copy of the state water well report and the geophysical log, if a geophysical log is available.

3. Well Information and Plugging Method

4. Owner's or Agent's Certification