SECTION I: WELL OWNER INFORMATION * First Name Last Name Address of Well Owner: * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone Number: * (###) ### #### Tax Parcel Number: SECTION II: WELL INFORMATION Location of the well: Latitude: Longitude: Physical description of the well location (if GPS coordinates are not available): * Note: A sketch of the well’s location on the subject project may be attached to this form. County that the well is located in: * Bulloch County Well Bryan County Well What is the type of well (check one)? * Drinking Water / Small Community Non-Drinking Water / Irrigation What aquifer is water produced from (if known): * Date Well Drilled: MM DD YYYY Driller: * Driller License Number: * Please attach a copy of the Driller’s Log, if available. General Well Information (if known, please fill out as much as possible): Land Surface Elevation Total Well Depth Screened Interval Depth of Water Well Diameter Diameter of borehole Depth Pump Set At Pump Type Pump Size Well Capacity Note: All elevations and depths shall be measured from below ground surface level. SECTION III: AFFIRMATION I certify the information contained herein is to the best of knowledge true and correct. Signature of the Well Owner * Thank you! Your information has been submitted. Someone will contact you soon about processing your claim. BRYAN - BULLOCH GSP WELL REGISTRATION
