Southeast Texas Groundwater Conservation District

Southeast Texas Groundwater Conservation District P.O. Box 1407 • 271 East Lamar, Jasper, TX 75951 Phone: (409) 383-1577 / Fax: (409) 383-0799 E-mail: [email protected] Exempt Well Registration Form

This form is to be used only for wells using less than 100,000 gallons per day (exception applies for wells associated with hydrocarbon exploration). Registration form must be completed and submitted prior to drilling. Anticipated Drill Date: ______Purpose for Water Use (please check one) [ ] Domestic [ ] Oil and Gas [ ] Agricultural [ ] Monitor Well [ ] Live Stock [ ] Church Well Owner Information Name of Property Owner: Telephone:

Mailing Address:

City: State: Zip: E-mail Address:

For Oil and Gas Companies Only Lease or well owner (if other than property owner):

Mailing Address:

City: State: Zip______Contact Name: Telephone:

Lease name or well site name: Railroad Commission API #:

Will well be used for Fracking? [ ] Yes [ ] No Estimated amount to be pumped:

Well Driller Information Name of Company:

Mailing Address:

City: State: Zip: Contact Name: Telephone:

Name of Licensed Driller: License #:

Well Specifications [ ] New Well [ ] Replacement Well (If so, indicate status of old well):

Casing Size: Pump Size: GPM: Depth of Well:

Well Location Physical address: City: State: Zip:

GPS Coordinates (required): Latitude: N: Longitude: W:

By signing this form, the driller declares that they are familiar with the District’s current rules and well construction standards and agree to abide by them. By signing this form, the well owner understands that this allows SETGCD to enter the property to inspect the well. By signing this form, both the driller and the property owner affirm that the well penetration site meets the spacing requirements set by the Texas Water Well Drillers Board. I hereby certify that I have furnished the above information and to the best of my knowledge and belief, all data herein contained are true and correct.

Well Owner Signature: Date:

Well Driller Signature: Date: