City of Coppell
P.O. BOX 9478
Coppell TX 75019
Fill out this application, attach the applicable fees, and return to the City office at the address above.
Well Owner: ________________________________________________________________________________
Address: ____________________________________________________________________________________
City: State: ____ Zip: Phone: _____________________________________________
Licensed Well Driller: _____________________________________Phone: _____________________________
Address: City State: Zip: ______
Well Location:
Provide specific directions to well site and attach copies of property plat, USGS 7.5' topography map,
subdivision map, or other large scale maps which may be available to help accurately locate the well site.
Well Information:
New Well  Modify existing well  Type of modification
Proposed Depth: Feet Aquifer: Trinity  Paluxy  Woodbine  Other
Proposed Depth to bottom of casing: Feet Inside Diameter of casing: Inches
Casing Type: PVC  Steel  ; New  Used  Proposed Pump Size: HP Capacity: GPM
Anticipated Drilling or Workover Date: Anticipated Completion Date: _______
Lot Size: ; Septic System: Yes No ; Is there another well on the property? Yes No
Water to be used for: Residential Domestic (number of homes served )  , Commercial Domestic  , Public
Water Supply  , Commercial  , Industrial  , Irrigation  Agricultural Livestock  , Monitor Well  , Earth
Coupled Heat Exchange  , Other 
I hereby make application to the City of Coppell to develop the water well described herein, and I certify that each
and all the statements herein are true and correct.
_______________________________________________ _________________________
Signature of Property Owner or Authorized Agent* Date
For City Use Only Special Conditions:
Public Water Supply
____ Residential/Domestic
Agricultural Approved  Denied 
Other Date:
Check # ___________ Receipt # ______________ Signed:
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