Application for New Well Permit

(Well has not been drilled)

Harris-Galveston Subsidence District 1660 W. Bay Area Boulevard Friendswood, TX 77546-2640 Phone: (281) 486-1105 Fax: (281) 218-3700

Instructions:  Submit this form for each aggregate well system. Send an application fee of $200.00 for each well within seven (7) days to the above address.

General Information Needed:  (Do not put any driller or engineer address information in General Information section if you are not the owner of the well)
Well Owner:
Attention:
Owner Email:
(If correspondence is being sent to a large organization, insert the specific person's name to whom you wish it directed. If self, enter self.)
Mailing Address:
City:	State:    Zip:
Owner's Phone #:	Ext.:
Health Dept. I.D.: (if applicable)

Well Data:
Physical Location of Well:
Latitude:	Degrees:		Minutes:		Seconds:
Longitude:	Degrees:		Minutes:		Seconds:
Total Depth:  ft.    Depth to First Screen:  ft.    Inside Diameter of Casing:  in.    Expected Production During the Next Twelve Months:  Million Gallons.     Amount of Surface Water purchased in previous Twelve Months:  Million Gallons.       Select intended use:     Public Supply - Wells used for retail or wholesale water supply.  (Examples: cities, water districts, private utilities, apartments, mobile home parks, etc.) Commercial/Domestic - Wells used by commercial or business establishments for potable or sanitary needs. (Examples: offices, warehouses, churches, schools, duplexes, etc.) Industrial - Wells used as part of an industrial process or in the manufacturing of a product. (Examples: boiler feed, paper manufacturing, chemical process feed, etc.) Agricultural Irrigation - Wells used in production of food or fiber commodities grown for resale or commercial purposes.  Includes wholesale nursery growers. Other - Wells used for other non-exempt uses such as livestock watering, filling ponds or lakes, or irrigation of golf courses, landscapes, parks, etc. Single-Family Residential - Wells connected to one single-family dwelling and used for typical domestic and sanitary needs. Single-Family Irrigation - Wells used for landscape irrigation at one single family residence but not connected to and serving the dwelling. Geothermal - Wells used for a geothermal heat exchanger. Specify whether closed-loop, reinjection, or pump and dump. Provide detailed description of intended use.  If commercial or industrial, describe type of business, number of employees, type of product produced or sold, etc.  If for new house or development, include construction start date.  If agricultural, include crop type and acreage.     Describe any other water supply available at this location.  For example, is there a municipal water line available for potable service or a canal or other raw water source for non-potable uses?     Status of this well as of given date:   Being Drilled Awaiting permit to begin drilling Year:     Year:     Aggregation:  If this well is to be placed in aggregate with other permitted wells, give lead well number of aggregation:     Does the "well owner" own any other well in Harris or Galveston county?  YesNoIf yes, explain:    Is this well replacing an existing well?   YesNoIf yes, give well no. of well being replaced   and length of time owned or leased:  If this well is a replacement well, what will be the status of the old well?Not a Replacement WellCappedPluggedIn UseIf status of old well is "In Use", explain:        Applicant/Agent Name:    Applicant/Agent Phone:    Ext.:   Please enter your e-mail address:      Please re-enter your e-mail address:      If this is a temporary or emergency application, you must also include the following information  and a fee of $100.00 for temporary applications for each well or  $200.00 for emergency applications for each well to the above address. Such action is: (check those applicable)     Suitable surface water is immediately available at the location.     An emergency need for groundwater exists. Reason for Emergency: (Why you cannot wait approximately 60 days for your Permit to be processed)