Demo Application Well Owner(Required) First Last Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address(Required) Phone(Required)Well Site Location (911 Address)(Required) Lot Size or # of Acres(Required) Property ID As shown on Burnet Central Appraisal District Tax Statement or Property SearchLatitude (if known) Longitude (if known) Proposed Usage Of Water From The Well – Check All That Apply: Domestic/Livestock Commercial Ag Irrigation Industrial Public Water Supply Estimated Annual Volume (if known) Proposed Maximum Pumping Capacity in Gallons per Minute (gpm) – Check One 0 to 17.36 gpm (most common) 17.36 to 50 gpm Greater than 50 gpm Single Well (Not connected to any other well or well system) Multi-Well System (connected to one or more wells that will together provide the water use identified above) Number of wells currently on this tract If any of the wells are associated with a District Operating Permit provide the Operating Permit Number Complete for New Well – a well for which drilling commenced on or after September 1, 2009Complete for Existing Well – a well that was in existence or for which drilling commenced prior to September 1, 2009Applicant Agrees to the Following: Water produced/withdrawn from the proposed well will be put to beneficial use at all times. If the well is located in a flood prone area, the well will comply with the applicable Rules of the Texas Department of Licensing and Regulation (“TDLR”) (16, Tex. Admin. Code, § 76.1000). Well spacing requirements of the TDLR (16, Tex. Admin. Code, Chapter 76) and the District Rules will be followed. If a Water Well Closure Plan is not attached in the case that this well would ever fail or become inactive, I will comply with (all applicable TDLR rules) for well closure (16, Tex. Admin. Code, Chapter 76) and that I will report closure of the well to the District. District staff may inspect a well or well location. Property access for inspections is authorized by Section 36.123 of the Texas Water Code, and District Rule 8.1. Local property restrictions including but not limited to city ordinances, deed restrictions, HOA or POA rules, utility districts, and municipal districts may have restrictions on drilling and operating wells. It is your responsibility to comply with your local property restrictions regarding the drilling of wells. The permits and/or drilling authorizations issued by the Central Texas Groundwater Conservation District do not confer any right to violate any local property restrictions. The information given herein is true and accurate to the best of my knowledge and belief and that I will comply with the Central Texas Groundwater Conservation District Rules and Management Plan. I further agree that if any change is made to the well, the pump, or the use of the water that would change the exempt or non-exempt status of this well, I will notify the District prior to making the change.Date MM slash DD slash YYYY Type Full Name The Signature on this Application must be that of the Well Owner as defined by the District Rules or the Authorized Agent of the Well Owner named in an executed Agent Authorization Form received by the District.