prefix *

 Mr.   Mrs.   Miss

Name-Surname / Name of authorized person *

National ID card number/corporate registration number *

Telephone number *

Purpose of using groundwater *

-- Select --Household consumptionAgriculture/watering plantsBusiness/Industry/ServiceConstruction/temporary workOther

Expected amount of water to be used (cubic meter/day) *

Water usage time *

-- Select --Use regularly throughout the year.Use during certain periods/seasonsTemporary use

Additional water usage details

Location of artesian well/groundwater use point *

Artesian well status *

-- Select --There is already an existing pond (request to use it).A new well will be drilled.Repair/improve the original pond

Approximate pond depth (meters)

Well pipe size/diameter (inches)

Water pump type (if any)