HICKORY UNDERGROUND WATER CONSERVATION DISTRICT NO

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HICKORY UNDERGROUND WATER CONSERVATION
DISTRICT NO. 1
P.O. Box 1214  111 East Main Street
Brady, Texas 76825
Phone (325) 597-2785  Fax (325) 597-0133
Email: [email protected]
Website: http://www.hickoryuwcd.org
REGISTRATION OF WATER PRODUCTION FACILITIES
Purpose: This form is to be used to gather information on wells that are exempted from obtaining a permit according the
Section 36.117 of the Texas Water Code, which are: a well used solely for domestic use for providing water for livestock or
poultry on a tract of land larger than 10 acres that is either drilled, completed, or equipped so that it is incapable of producing
more than 25,000 gallons of groundwater a day; the drilling of a water well used solely to supply water for a rig that is actively
engaged in drilling or exploration operations for an oil or gas well permitted by the Railroad Commission of Texas provided
that the person holding the permit is responsible for drilling and operating the water well and the well is located on the same
lease or field associated with the drilling rig; or the drilling of a water well authorized under a permit issued by the Railroad
Commission of Texas under Chapter 134, Natural Resources Code, or for production from such a well to the extent the
withdrawals are required for mining activities regardless of any subsequent use of the water. A separate registration must be
completed for each well.
Registration/Well Number:
Date Received:
(Complete only items below this line)
I.
II.
Applicant Data
A.
Name of Applicant ___ ____________
_________
B.
Mailing Address
______ ______________ ____________
_____ ____________
_______
C.
Telephone_______________________________
D.
Relation of the subscriber to this registration is that of ____________ (Owner, tenant,
agent or otherwise) and he is authorized to make this application in behalf of the interest
affected.
Nature and Extent of Use
A.
The quantity of water used from the well listed in this registration is in the amount of
________ acre feet per calendar year. (One acre foot = 325,851 gallons)
B.
Are there other wells listed within other registrations or applications that are used in
conjunction with the operation listed in this registration? _________
If yes, list registration well number: ______________
C.
The water is diverted at a maximum rate of ________ gpm.
D.
Date well was/will be completed: _____ ____________
E.
The production of water was/will be initiated on _______
F.
Driller:_ ___________________
Address:___
__________________________
G. The water has been/will be used for: (check use or uses and show amount for each)
1.( ) Domestic ________________________
2.( ) Stock ___________________________
3.( ) Other____________________________
(over)
III.
IV.
Location Information
A.
Location of Production Well
The legal description of the land on which the well is located:
Survey Name:_____________________
Survey Number:___________________
Abstract Number:__________________
County:_______________
B.
A general description of the location of the well is:
__ ______________________________________________
Attach a map or plat showing the following: (see map)
1.
The scale
2.
A north arrow
3.
The location of existing or proposed well
4.
The location of other wells under other registration to be used in the project.
Completion Information
If well is already completed, provide the following information for the well.
1.
Depth to top of aquifer (feet)_________________________
2.
Depth to the bottom of the aquifer (feet ________________
3.
Total depth of well (feet)__ _________
____
4.
Bore diameter (inches)___________________ ________
5.
Depth of casing (feet)__ ____________________________
6.
Inside diameter of casing____________________________
7.
Static water level ___________ _______________
8.
Depth of pump setting (feet)__ __________________
9.
If available, attach a copy of drillers log or water well report.
I hereby certify that the information provided herein is, to the best of my knowledge, true and correct.
Signed:______________________________________
Printed Name:_________________________________
Date:_______________________
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