Water Well Plugging Application

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

property owner name *

First

last *

Last

email *

phone number *

address *

city *

state *

postal code *

contact name for property owner *

phone number *

agent name *

agent company name *

agent company mailing address *

city *

state *

postal code *

drilling contractor company name: *

driller name *

lic. #: *

phone number *

driller mailing address: *

city *

state *

postal code *

2. Well Site Information and Proof of Ownership

well site address: *

latitude *

longitude *

description of well location on property: *

* 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

total estimated depth of grout placement below land surface (feet): *

well Depth (feet): *

casing type: *

casing diameter: *

static water level: *

screen (feet): *

describe and attach a diagram of the plugging method: *

4. Owner's or Agent's Certification

Signature *

Clear

Date *

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1. Applicant/ Owner Information

2. Well Site Information and Proof of Ownership

3. Well Information and Plugging Method

4. Owner's or Agent's Certification

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