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2. Well Number
   Assigned by Lost Pines Groundwater Conservation District (LPGCD)
3. Application Date
   Application Date
   Date Received in LPGCD
5. Is this well within a subdivision?

   1. Yes

   1. No
7. Section I - Applicant
9. Name
   First, Middle Initial, Last
10. Phone Number
12. Street or P.O. Box
14. City
15. State
16. Zip
18. Name and address of property owner if different from person shown above
20. Name
    First, Middle Initial, Last
22. Street or P.O. Box
24. City
25. State
26. Zip
28. Section II - Exemption
    LPGCD can help with information in this section, if needed.
30. Request for exemption under Lost Pines Groundwater Conservation District Rule 8.6?

    1. Yes

    1. No
32. Type of Exemption Claimed

    1. A well drilled or equipped that is incapable of producing more than 25,000 gallons of groundwater per day.
    2. A well used to supply the domestic needs of 10 or fewer households.
    3. A well for water used for feeding livestock and poultry.
    4. An affidavit is on file with the District stating that production of well shall be limited to less than 25,000 gallons per day.
    5. Other
34. Please explain the exemption if other was checked.
36. Section III - Well Information
38. Well Location
    Directions to Well Site
40. Well is Located in:

    1. Bastrop County

    1. Lee County
42. Please attach copies of the following schedules or logs, if available.
44. Driller’s Schedule
45. Driller’s Log/Report
46. Electric Log
48. Date Well Drilled
49. Driller’s Name
50. Driller’s License Number
52. Well Depth in Feet
53. Diameter of Hole of Inches
54. Diameter of Pipe in inches
56. Pump Set at (Depth of Lift) in Feet
57. Depth to Water in Feet
59. Pump Size in Horse Power
60. Well Capacity in Gallons Per Minute
62. Pump Power Source
63. Type of Pump
65. Type of Well

    1. Domestic

    1. Irrigation

    1. Municipal

    1. Other
67. Please explain type of well, if other was checked.
69. Type of Use of Water
70. Pumping Potential in Gallons Per Day
72. LPGCD can help with information in this area, if needed.
74. Aquifer Water is Produced From
75. Screened Intervals in Feet
77. Latitude Location of Well
78. Longitude Location of Well
80. Surface Elevation in Feet Above Sea Level
82. Section IV - Affirmation

    I certify that all statements and information in this application are true and correct.

    1. I agree
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84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

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