TNR

Voluntary Well Information Report Form

If you have experienced problems with the water-level in your well please complete as much the form below as you are comfortable filling in to assist us in gathering information regarding water levels changes within the area. Information you submit may be subject to public information requests, so only submit as much info as you are comfortable with the public potentially seeing.

This information is important to Travis County in obtaining a better understanding of water supply issues in Travis County. Thank you for helping us understand the aquifer better.

First name (required):

Last name:

Report Date:
5/26/2012

Address:

Phone:

Email:

Date well was orginially drilled:

Initial water level:

Well Information When Dry

Date well went dry:

Well depth

Pump depth

Actions Taken to Address Problem

Action taken:

Date of Action:

Resulting well depth:

Resulting pump depth:

Well service provider & details of actions taken:

May we contact the service provider for additional information? (Check to allow.)

Historical Well Information

Well depth, water level and pump depth by date. Note whether actual or estimated.

Name of the aquifer or water bearing zone of the well.:

Additional Information

Other people in your area with similiar well problems:

Other comments:


Please enter the verification code shown in the image above:

Voluntary Well Information Report Form

Well Information When Dry

Actions Taken to Address Problem

Historical Well Information

Additional Information

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