1 Name of the Applicant

2 Category Govt.

3

4

5

6

7 Numbers of Bore-Wells

8

9

10 Size of Bore-Wells

11 Date of Installation

(dd/mm/yy) (dd/mm/yy) (dd/mm/yy) (dd/mm/yy) (dd/mm/yy)

12 Yes/No

dd mm yy

Date of Registration

13 (a) Domestic

(b) Commercial

(c ) Indusrial

(d) Agricultural

(e) Any other (specify)

14 Details of Water Connection, if any

(a) Yes/No(b) Bulk

It is certified that the information furnished by me is true to best of my knowledge & belief.

Date:

Place: Name & Signature of Applicant

Whether Registered with CGWA/Govt. Agency

Application For Voluntary Disclosure of Existing Bore-Wells/Tube-Wells

(To be submitted in Triplicate)

Non Govt./Individual

Individual

Commercial

Type of Connection

(Tick which is applicable)

Industrial

Any Other(specify)

Telephone/Mobile No.

Whether water connection available

Purpose of Ground Water Drawl

(Tick purposes which are applicable)

Address (with PIN)

Email:

Location of Bore-Well(s)

Type of Wells (Motorised/Hand Pump)

Capacity of Pumps (in HP)