2. FORM 100

   Well Drilling Application

6. SECTION I – APPLICANT
8. First Name*
9. Last Name*
11. Company (if applicable)
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Email Address*
24. SECTION II – DRILLING SITE DESCRIPTION
26. Physical Address, or Description of Proposed Drilling Site (use GPS coordinate if known.)*
28. County that the Drilling Site is Located in:*
    -- Select One --BastropLee
30. Is the proposed well located within a neighborhood or subdivision?*
    -- Select One --YesNo
32. If Yes, which neighborhood or subdivision?
34. If an address is not available, what is the County Appraisal District property number?
36. What is the acreage associated with this property?*
38. If less than 10 acres, is a connection to a water utility, municipality, WCID, or other water source available?
    -- Select One --YesNo
40. Are all well spacing and property line spacing requirements being met according to LPGCD Rule 8.2?
    -- Select One --YesNo
44. SECTION III - PLANNING AND DESIGN

    A copy of The State of Texas Well Report must be sent to the LPGCD upon completion.

    Have the well driller check the LPGCD website online Well Database and Bore Tool to determine the best depth for this new well: https://lostpinesgcd.halff.com/Map/Public

46. Well Driller Name*
47. Well Driller Email*
49. If known, what is the proposed aquifer that the well will produce from?
50. What will be the approximate total depth of the well in feet?
54. SECTION IV – WELL INFORMATION
56. Will the Applicant be requesting an exemption under LPGCD Rule 3.1?*
    -- Select One --YesNo
58. If Yes, type of exemption claimed:*
    -- Select One --A well that is solely for domestic, irrigation, or livestock use that is incapable of producing more than 25,000 gallons per day (gpd).A well that uses less than 200 acre-feet/year solely for agricultural use. This well must be metered.A well that is 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.A water well authorized under a permit issued by the Railroad Commission of Texas for mining activities.A water well drilled and completed solely for the purposes of aquifer testing.Not requesting exemption
62. SECTION V – AUTHORIZATION TO DRILL

    NOTE: The well driller must provide the LPGCD permit authorization at the well site upon inspection.

64. Is the Applicant the same as the Groundwater Owner of the Proposed Drilling Site?*
    -- Select One --YesNo
66. If the Property Owner is different from Applicant shown in Section I, contact information and a notarized letter of authorization to drill from the property owner MUST be uploaded here.
70. SECTION VI – AFFIRMATION
72. In signing this I certify that all statements and information in this application are true and correct.*

    Please type your first and last name as a digital signature.

73. Date*
    Date

    Please enter today's date.

Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field