WELL OWNER INFORMATION: * First Name Last Name Address of Well Owner: * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number: * (###) ### #### REASON FOR MITIGATION REQUEST: * Date Problem Encountered: MM DD YYYY Is this well registered with the Bulloch/Bryan County Well Mitigation Program? Yes No Is this for drinking water or non-drinking water? * Drinking Water Non-Drinking Water Signature of the Well Owner: * Date MM DD YYYY By this digital signature I am granting the GSP and/or its contractor access to the property on which the water well is located to conduct well assessment activities and any future date gathering for water levels from the well. Thank you! Your information has been submitted. Someone will contact you soon about processing your claim. BULLOCH COUNTY AGRICULTURAL WATER WELL MITIGATION TRACK CLAIM
