Change in Well Condition or Status Form

Check All Applicable (required)

This well is being permanently plugged.

This well is being capped and taken out of service and is in a non-deteriorated condition.

The type of use of this well is being changed.

This well is being altered in size or depth.

The annual pumping volume, pump size, or rated pumping capability of this well is being increased.

The pumping capability of this well is being decreased.

Well Owner Information

Well Owner (required)

Mailing Address (Street/P.O, City, ZIp) (required)

Daytime Phone (required)

Alternate Phone

Contact Person (if other than owner)

Contact Phone

Location, Description, and Uses of Well

District Well Registration #

Sate or Temporary Well #

Lot or Tract Size (acres)

Directions to Well (or attach location map below) (required)

Location Map

Driller

Drilling Date, if known

Is Well Operational (required)

Yes

For existing wells, attach copies of Driller’s Log and any Pump Data if available.

Water Used (required)

On-Site

Off-Site

If off-site, please specify where used

Does this well have an Operating Permit?

Yes

Permit application submitted and pending action

Annual Permitted Pumpage in gallons (or proposed Annual Pumpage if Permit application is pending)

Report All Proposed Changes to Well, Well Pump, or Usage. (The well owner and/or driller must discuss the proposed plugging plan or procedure with District staff prior to plugging well) Please check one option below

Well is to be permanently plugged on or about (date)

by (name of driller)

Well is in a non-deteriorated condition and to be capped and taken out of service on or about (date)

Current Use of Well

Proposed Use of Well

Current Total Depth of Well if known: (ft)

Proposed Total Depth of Well if known (ft)

Current Pump Horsepower if known

Proposed Pump Horsepower if known

Current Pumping Capability in GPM if known:

Proposed Pumping Capability in GPM if known:

Current Casing Diameter if known: (in.)

Proposed Casing Diameter if known: (in.)

Current Casing Depth if known (ft)

Proposed Casing Depth if known (ft)

Attachments Provided with This Form

Copy of District Well Registration Form

Copy of District Operating Permit

Well Location Map or Property Plat. Must be drawn to a scale that adequately details the well site, well site access route, property lines, location of other existing or proposed wells on the tract, existing wells on adjoining tracts which may lie within the spacing required for the proposed well, location of surface storage, location of existing water uses if any, location of existing or proposed on-site wastewater systems, and the location of any other potential source of pollution.

Written Plugging Plan or Procedure. Required only if different from the procedures described in 16 TAC Chapter 76.

Other File

Owner’s or Applicant’s Sworn Statement (required)

I hereby swear and affirm that the information given herein is true and accurate to the best of my knowledge and belief.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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