1. (I)Name of the applicant & company name. (II)Father s / Husband s Name in the case of individuals. (III)Complete Postal Address

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1 APPLICATON FOR ISSUE OF GROUND WATER CLEARANCE / NO OBJECTION CERTIFICATE FOR INDUSTRY / CONSTRUCTION / HORTICULTURE / COMMERCIAL / INFRA STRUCTURES / OTHER USERS 1. (I)Name of the applicant & company name (II)Father s / Husband s Name in the case of individuals. (III)Complete Postal Address 2. (I) Name of owner of the land where Proposed Pumping well is Existing (if the applicant himself is not the owner) (II)Postal address (III) Firka Name : (IV)Taluk Name : (V) District Name : (VI) Condact Phone Nos : 3. (I)Place of ground water extraction Proposed. T.S / S. F No. : Village / town / Division : Firka Name : Taluk Name : District Name : (II) Place of ground water Utilization. T.S / S. F No. : Village / town / Division : Firka Name : Taluk Name : District Name :

2 4. Purpose for which water is to be extracted or Used -Industry / Construction / Horticulture / Commercial / Infrastructures / other uses. 5. Required quantity of water (I) Surface Water : (II) Ground water : 6. Status of proposed well for extraction Existing : 7. Details of Existing well if any : (a)type of well- Dug well / Dug cum Bore Well / Bore well /Open well /Tube well (b) Diameter of well ( in metre) (c) Depth of well (in metre) (d) In the case of dug cum bore well give Details of both open and bore well. (e) Recuperation hours (d) Rock type Hard rock / Sedimentary / Alluvium (can be blank if not known to the applicant) 8. Whether well is located in Ayacut / Non ayacut area. 9. Command area of well in Acres / Hectare: 10.Crops grown : Type I Crop II Crop III Crop 11. Details of pumps proposed / installed. (a)type of pump Centrifugal / Turbine/ Submersible / jet / Compressor / others. 12. Hours of pumping per day 13. Nearest well distance (in Metre)from the Proposed extraction well (certificate to be enclosed.

3 14. Nearest stream, river, tank(in metre) from the proposed extraction well (certificate to be enclosed ). 15.No.of any other wells in the location. : 16.Categorisation of Firka Over exploited / Critical /Semi critical /Safe(can be left blank if not known to the applicant ). : DECLARATION I hereby declare that the above particulars are true to the best of my knowledge and I herewith enclosed all the certificates and documents for Departmental perusal.based on the document verification only the service charges are paid to the Government. I will forego the charges and I will not claim the refund of service charges in the case of incorrectness of facts in the certificate. Place : Date : Signature of the applicant.

4 Application-Annexure I Certificate on Spacing between wells Certified that the spacing between the Applicant Thiru./Tmt for M/s proposed pumping well, located in S.F. No of Village, in Firka, Taluk, District and the adjacent / surrounding wells., 1. First well s (in S.F No.) depth is m and the spacing is m, 2. Second well s (in S.F No.) depth is m and the spacing is m, 3. Third well s (in S.F No.) depth is m and the spacing is m, 4. Fourth well s (in S.F No.) depth is m and the spacing is m, 5. Fifth well s (in S.F No.) depth is m and the spacing is m, 6. Sixth well s (in S.F No.) depth is m and the spacing is m, Revenue Inspector

5 Application-Annexure II Certificate on Spacing between proposed pumping wells and Palar river bank. ( vide G.O (Ms) No.1766 PWD dated ) Certified that the spacing between the Applicant Thiru/Tmt for M/s proposed pumping well, located in S.F. No of Village in Firka, Taluk, of district and the Palar River Bank is above 200 m vide above cited G.O. / does not fall in the Palar River basin. And Certified that the Applicant Thiru/Tmt for M/s proposed pumping well, located in located in S.F. No of Village in Firka, Taluk, of District does not fall with in the vicinity of 250 m from any public drinking water sources. Revenue Inspector

6 Application-Annexure III Certificate to be issued by Local body Certified that the Panchayat / Municipality / Corporation has No OBJECTION for pumping Litres of Ground water from the well located in S.F. No of Village in Firka, Taluk of district belongs to the applicant Thiru/Tmt for M/s proposal for the proposed industries / construction / infrastructure projects and for all other commercial purposes and to transport ground water from the above location to different places. President, Panchayat / Municipality / Corporation

7 Application-Annexure IV Certificate on Spacing between proposed pumping wells and Selected River banks. (Vide G.O (1D) No.223 Environment & Forest (S3) Department dated ) (Applicable only to the 14 types of industries cited in Annexure of G.O (Ms) No.213, for Cauvery and its tributaries, Pennaiyaru, Palar, Vaigai & Thamiraparani Rivers) Certified that the spacing between the Applicant Thiru for M/s proposed pumping well, located in S.F. No of Village in Firka, Taluk, of District and the River Bank is above 5 km vide above cited G.O. Revenue Inspector

8 Application-Annexure V Certificate on Spacing between proposed pumping wells and Sea coast. (Vide CE / SG&SWRDC Technical circular No.5 / 2010 / DD (G) /dated ) Certified that the spacing between the Applicant Thiru/Tmt for M/s proposed pumping well located in S.F. No of Village in Firka, Taluk, of district and the sea coast is km away / above 10 Km away from the coast. (Note: If the distance exceeds 10 km, exact distance need not be mentioned) Revenue Inspector

9 Application-Annexure VI Certificate of Assurance (Vide CE / SG&SWRDC Technical circular No.3 / 2010 / DD (G) /dated ) I, Thiru/Tmt ,applicant for M/S for the groundwater drawal located in S.F. No of Village in Firka, Taluk,of , District, give the following certificate to the Chief Engineer / SG &SWRDC, PWD/WRD. I assure that in the case of the, SG &SWRDC, WRD, issue the Ground water Clearance to me / the firm, for industrial / commercial / Infrastructures purposes, the electricity connection obtained for the purpose of Agriculture will be changed to Commercial Purpose. Failing which,i agree to cancel the Groundwater Clearance issued by SG &SWRDC, WRD on behalf of Government of Tamilnadu. Applicant Witness: 1. 2.

10 Application-Annexure VII Certificate of Assurance I, Thiru , applicant for M\S for the groundwater drawal located in S.F. No of Village in Firka, Taluk, of , District, give the following certificate to the Chief Engineer / SG &SWRDC, PWD/WRD. I assure that in the case of the, SG &SWRDC, PWD/WRD, issue the Ground water Clearance to me / the firm, for industrial / Commercial / Infrastructures purposes, located in S.F. No of Village in Firka, Taluk, of District, the Rain Water Harvesting Structure, as specified by the Department will be constructed. Failing which,i agree to cancel the Groundwater Clearance issued by SG &SWRDC, PWD on behalf of Government of Tamilnadu. Applicant Witness: 1. 2.

11 Application-Annexure VIII Certificate of Assurance I, Thiru , applicant for M\S for the ground water Drawal located in S.F. No of Village in Firka, Taluk, of , District, give the following certificate to the Chief Engineer / SG &SWRDC, PWD. I assure that in the case of the, SG &SWRDC, PWD/WRD, issue the Ground water Clearance to me / the firm, for industrial / Commercial / Infrastructure purposes, located in S.F. No of Village in Firka, Taluk, of District, a separate bore well will be constructed, maintained and handed over to SG &SWRDC in the above location for monitoring the water level. Applicant

12 Application for the Groundwater Clearance -NOC-List of Documents to be enclosed with the Application 1. Attested copy (Notary public) of registered land ownership document in the name of applicant or registered lease agreement for a minimum period of 10 years in the name of applicant. 2. FMB Sketch (for well and industry Locations). 3. Not to scale topo sketch showing the location of the applicant wells and the industry, surrounding wells with the spacing. 4. Chitta &Adangal copy 5. Copy of EB card with tariff paid details (Commercial connection). 6. Annexure I - The distance between the proposed well for groundwater extraction and nearest wells and the depth of the wells to be certified by the revenue inspector of that area. 7. Annexure II - The distance between the well proposed for extraction and the bank of Palar river (Palar basin rules) to be certified by the revenue inspector of that area (which is applicable for Palar basin area) and the certificate of the distance between proposed well and nearby Drinking Water supply scheme wells. 8. Annexure III - No objection certificate from the concerned village Panchayat for the proposed quantity of groundwater extraction and transportation of ground water if any. 9. Annexure IV - The distance between the well proposed for extraction and nearest surface water body such as tank, canal, stream, river etc., to be certified by the revenue inspector of that area. 10.Annexure V - The distance between the proposed well for groundwater extraction and the coastal line (beach) to be certified by the revenue inspector of that area 11. Annexure VI - Undertaking letter by applicant regarding the change of EB service for agriculture to commercial in the event of awarding groundwater availability certificate. 12. Annexure VII Undertaking from the applicant towards construction of RWH if groundwater availability certificate is awarded. 13. Annexure VIII - Applicants should submit the undertaking that they must erect and handover one borewell to the for observation of water level and quality. 14. Annexue IX (Certificate from local body for Surface Water Supply) 15. Latest EC (for the last 3 years) 16.Under taking of the applicant regarding the pumping test for issuing NOC. 17. Indemnity Bond with Notary public attestation 18. If existing company copy of ISI Certificate, TNPCB Certificate, Food safety certificate etc.,

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