Request for a Variance from BPGCD Rules

This form is used for requesting a variance from BPGCD Rules only and shall be filled out as completely as possible.

Instructions: This form is used for requesting a variance from BPGCD Rules only and shall be filled out as completely as possible.

Check All Applicable (required)

Variance requested for property line spacing Rules.

Variance requested for well-to-well spacing Rules.

Variance requested for other Rules. Please specify:

Well Inspection: District staff shall inspect each well requesting a variance. Property access for inspections is authorized by Texas Water Code, Chapter 36.123 and shall be scheduled with the well owner and conducted in accordance with District Rule 3 and Rule 4.5. Inspections may include confirming well location, measuring water level, confirming pumping capability, water sampling, geological survey, or any other well-related inspection activity deemed necessary by the District.

Well Owner

Well Owner Name (required)

Mailing Address (Street/P.O., City, Zip) (required)

Daytime Phone (required)

Alternate Phone

Contact Person (if other than owner)

Contact Phone

Location, Description, and Uses of Well

District Well Registration # (required)

State or Temporary Well #

Lot or Tract Size (acres)

Directions to Well (or attach location map) (required)

Location Map

Driller

Drilling Date if known

Water to be used (required)

On-Site

Off-Site (specify below)

If off-site, please specify where used

If requesting a variance on BPGCD minimum spacing requirements, the owner or well driller must provide the distances in feet between the new well and any existing or proposed:

Closest Property Line (required)

Other Wells (required)

Septic Tank (required)

Septic Leach Field (required)

Other Potential Sources (specify)

Provide an explanation about your need for the requested variance(s): (required)

Attachments provided with this form:

Copy of District Well Registration Form

Copy of District Operating Permit

Well Location Map or Property Plat. Must be drawn to a scale that adequately details the well site, well site access route, property lines, location of other existing or proposed wells on the tract, existing wells on adjoining tracts which may lie within the spacing required for the proposed well, location of surface storage, location of existing water uses if any, location of existing or proposed on-site wastewater systems, and the location of any other potential source of pollution.

Written Plugging Plan or Procedure. Required only if different from the procedures described in 16 TAC Chapter 76.