Pump Installation Report

Pump Installers must fill out and submit this form for each pump they installed in Blanco County.

Pump Installation Report 20260401.pdf

To be completed by the pump installer and returned to the District

Well Registration Number: (if know)

Well Owner’s Name: (required)

Well Location: (required)

Pump Installer Company (required)

Pump Installer Name: (required)

Installer License Number: (required)

Address of Installer:

Installer Email:

Installer Phone: (required)

Date of Installation: (required)

Latitude (required)

Longitude (required)

Casing Size (I.D.): (required)

Production Pipe Size

Pump Depth Below Top of Casing

Pump HP Rating (required)

Pump Make & Model (required)

Maximum pumping capacity of pump as installed (GPM ): (required)

Is Inspection Port easily accessible? (required)

Yes

Was the well disinfected upon completion of work? (required)

Yes

Comments

Certification Statement (required)

I hereby certify that the pump information given herewith is true and correct.

Your Signature (required)

By signing this document, I hereby swear or affirm that the information given herein is true and accurate to the best of my knowledge and belief, and that I will comply with the Rules of the Blanco Pedernales Groundwater Conservation District. I acknowledge that any false statement is punishable by perjury under Texas Law.

Your Signature

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