GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 
======== 
DEPARTMENT OF PLANNING AND NATURAL RESOURCES 
DIVISION OF ENVIRONMENTAL PROTECTION 
45 MARS HILL 
FREDERIKSTED, ST. CROIX, VI  00840 
PHONE: (340) 773-1082, FAX: (340) 773-9310 
 
APPLICATION FOR PERMIT TO DRILL WELL 
 
In compliance with Title 12, Chapter 5, Virgin Islands Code, the undersigned  
______________________________________________________________________________ 
Name of Driller & License Number 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Mailing Address  
______________________________________________________________________________ 
Telephone Number 
Hereby applies for a permit to: 
 
__________ Drill a well 
__________ Deepen an existing well 
__________ Clean and refurbish an existing well  
 
On the property: 
 
________________________________________________ 
 
(Name of Property Owner) 
 
________________________________________________ 
 
(Estate, Lot Number and Island) 
 
_______________________ 
 
(Property Tax Number) 
 
The well will be drilled to the approximate depth of ______ feet and will be ______ inches in 
diameter.  It will have ______ feet of casing, constructed of ________________ material, 
______ feet of screening of _____________________ (description of screen) and will have 
___________________________ (proposed type of casing seal).  
 
___________________________________________________________________________ 
Purpose of well 
 
Well Driller responsibilities’: 
 
1. Provide an he attached property map from Cadastral Survey shows the following:  
a) Location of proposed well relative to existing buildings or other physical features. 
b) Location of existing wells on the property or nearby adjacent properties. 
c) Location of all known sources of contamination in the vicinity. 
 
2.The pump and the meter will be installed by well driller,  provide the following information: 
 
     Capacity of Pump ________ Horsepower ________ Size ________ 
 (GPM) 
 
     (HP) 
    (Inches) 
 
3. A log showing the various strata or formations intersected by the well, formation yields and 
quality, and casing and screening details will be forwarded to the Division of Environmental 
Protection within 30 days after completion of drilling operations. 
 
 
Fee of $10.00 is attached.  (If check, please make payable to the Government of the Virgin 
Islands). 
 
_____________________________  
 
________________ 
Signature of Property Owner  
 
 
Date 
 
_____________________________  
 
________________ 
Signature of Well Driller  
 
 
 
Driller’s License No