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

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

No

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

Yes

No

Comments

Certification Statement (required)

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

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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