As required by District Rule 3.5C, any change of ownership of a well must be reported by the new well owner by completed and submitting a Change of Well Ownership Form to our District within 90 days after the ownership change.

Instructions: This form is used for a change of well ownership only and shall be filled out as completely as possible. In accordance with District Rule 3.5.C, any change of ownership of a well in Blanco County must be reported to the District.

Please Check Appropriate Box(es) (required)

This well is registered with the District. (Provide Registration Number below.)

This well has an Operating Permit issued by the District.

It is believed that this well is not yet registered with the District.

Registration Number

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WELL REGISTRATION: The District shall confirm whether or not the well is registered with the District and if it is exempt or non-exempt from permit requirements. If registration or a permit is required, the District will provide the new well owner with the appropriate application forms which must be completed and returned to the District office.

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Previous Well Owner

Name (required)

Address (Street or P.O.Box, City, Zip) (required)

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New Well Owner

Name (required)

Address (Street or P.O.Box, City, Zip) (required)

Daytime Phone (required)

Alternate Phone

Contact Person (if other than owner)

Contact Phone

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Location, Description, and Uses of Well

Lot or Tract Size (Acres)

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

Upload Location Map

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Well Information

Driller

Drilling Date

Well Depth (ft.)

Pump Depth (ft.)

Pump Horsepower

Pumping Capability in GPM

Casing Diameter (in.)

Is Well Operational (required)

Yes

No

Abandoned

Attach copies of Driller’s Log and any Pump Data if available.

Water Used (required)

On-Site

Off-Site

If offsite, please specify where used

Water Used For (required)

Domestic

Livestock

Public Water Supply

Irrigation

Testing

Monitor

Industrial

Pond

Other (specify below)

If domestic, provide number of households served by this well (required)

If other, specify

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If this well has an Operating Permit issued by the District, please provide the following information:

Permitted Maximum Annual Production (gallons)

Pumping Capability (GPM)

Will usage change?

Yes (describe change below)

No

If yes, describe the change in use

Will annual production change

Yes (if yes, specify change below)

No

If yes, provide estimated annual pumping:

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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