Title *

 Mr.   Mrs.   Ms.

Name-Surname / Name of authorized person *

ID card number/corporate registration number *

Phone Number *

Purpose of using groundwater *

-- Select --Household consumptionAgriculture/Plant wateringBusiness/Industry/ServiceConstruction/temporary workOther

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

Water usage time *

-- Select --Use regularly throughout the year.Used during certain periods/seasons.Temporary 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).Will drill a new well.Repair/improve the original pond.

Approximate pond depth (meters)

Well pipe size/diameter (inches)

Water pump type (if any)