University Lands
The University of Texas System
704 W. Denger Ave, Midland, Texas 79705-5319
P.O. Box 553, Midland, Texas 79702-0553
Phone (432) 684-4404 Fax (432) 682-7456
www.utlands.utsystem.edu
APPLICATION FOR APPROVAL TO PUMP A WATER WELL
A well for which drilling commenced on or after January 1, 2013.
Pumping must be suspended if this form is not submitted within 30 days from installation of the pump.
Operator’s Designated Name for Well: ___________________________________ Application Date: _______________
Approved by: __________________________________________________________Approval Date: ________________
Part I – Well Owner, Operator, and Driller Information:
Drill Start Date:____________________________ Well Completion Date: ______________________________
Well Owner: _______________________________________________________ Phone: ____________________________
Contact : ____________________________ E-Mail: _____________________________Fax: ________________________
Mailing Address: ___________________________________________ City: ___________ State: ___ Zip: ______________
Registrant (if other than well owner): ______________________________________ Phone: _________________________
Mailing Address: ___________________________________________ City: ___________ State: ___ Zip: ______________
Email: ______________________________
Operator’s Company: _____________________________________ Phone:_______________________________________
Mailing Address: ___________________________________________ City: ___________ State: ___ Zip: ______________
Email: ______________________________
Drilling Company: __________________________________________________________ Phone: ____________________
Driller: _______________________________________ License #: ___________________ Expiration Date: ____________
Fax: ___________________________________ E-mail: ______________________________________________________
Mailing Address: ___________________________________________ City: ___________ State: ___ Zip: ______________
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Part II – Well Location:
 Did Well Location Change from Application Location? Y or N Provide updated maps for well.
Block: _______________ Section: ____________________ County: ____________________________________________
Latitude: ___________________ Longitude: ___________________ (Lat / Long must have a minimum of 6 decimal places.)
GPS manufacturer and model used to measure latitude and longitude: ____________________________________________
Accuracy of the GPS measurement: _______________________________________________________________________
Part III – Required Documents:
Place an (X) to verify that each document is included in the application (refer to University Lands Guidance Document for
Approval to Pump a Dockum (Santa Rosa) Water Well):
___ Final Aerial Map
___ Final U.S. Geological Survey 7.5-minute Topographic Quadrangle Map
___ State of Texas Well Report
___ Third Party Onsite Monitor’s Summary of the Drilling and Well Completion
___ Well As-Builts Stamped by a Professional Engineer
___ Water Analysis Report
___ 12 Hour Pump Test with Recovery Data
___ Cementing Certificate (W-15)
___ Geophysical Logs with Annotations
Part IV Verifications:
State of Texas Well Report has been submitted to the___________________GWCD. Y or N
I verify that cement returned to the surface.
Signature:__________________________________________________
Part IV – Well Submittal Packet Synopsis:
The well location is approximately _______________ feet from the nearest water well.
The screened interval of the nearest water well: ________________________________________________
Well
Depth of well: _____________ feet below ground level
Borehole diameter: ________ inches
Casing diameter: __________ inches
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Casing material: _______________
Coupling diameter (if applicable): ________ inches
Depth of casing: __________ feet below ground level
Top of casing: _____________ feet above ground level or above 100 year flood plain (if applicable)
Top of screen: ____________ feet below ground level
Screen type: __________________
Screened interval(s):____________________________________ feet below ground level
Filter pack interval: _________________to_______________ feet below ground level
Top of pump: ____________________feet below ground level
Airline setting: ___________________ feet below ground level
Pump diameter:______________ inches.
Motor size: _______________ hp
12 hour production rate and pumping water level: ___________ gpm at _______________ feet below ground level
Part V – Certification:
I hereby certify the following: the information given herewith is true and accurate to the best of my knowledge and
belief and that the proposed well will have no effect on existing water wells.
Professional Engineer
__________________________________________
Print Name
Date
Seal:
Professional Geologist
__________________________________________
Print Name
Date
Seal:
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