APPLICATION FOR ISSUE OF NO OBJECTION CERTIFICATE TO

EXTRACTGROUNDWATER FOR NEW (OR) EXISTING INDUSTRY / FIRM / COMPANY /

PLANT / OTHER USERS WITHIN THE PREMISES / BY TRANSPORT (WATER INTENSIVE /
NON WATER INTENSIVE)

1. Name of the Applicant /Company name :

2.Father’s/Husband’s Name (in case of individual) :

3. Complete Postal Address & Contact No. :

4. Applicant own land / Registered Lease Agreement :

5. Place of ground water extraction proposed

i. T.S / S.F No. :

ii. Village name (If it is a hamlet

village, write Revenue village name) :

iii. Firka name & Category :

iv. Taluk name :

v. District name :

6. Place of ground water Utilization/ Transporation proposed

i. T.S / S.F No. :

ii. Village name (If it is a hamlet village

write Revenue village name) :

iii. Firka name & Category :

iv. Taluk name :

v. District name :

7. Ground water requirement for : New / Existing

(i) Type of Industry/Firm/Company/Plant :

8. Required Quantity of ground water : lpd

9. Details of existing well

i. Type of well : Dug well/Dug cum bore well/Bore well/Tube well

ii. Diameter of well (in m.) :

 iii. Depth of well (in m. ) :

iv. Rock type : Sedimentary / Hard rock formation

10. Well location : Ayacut / Non Ayacut / Residential

(i) If Ayacut / Residential (Copy of land conversion proposal applied to the concern department)

11. Types of Pumps used for extraction : Centrifugal/Turbine/Submersible/

Jet/Compressor/Others

(i) Horse Power (HP) :

12. Hours of Pumping per day :

13. Total Number of wells :

14. Distances from nearest water bodies :

i. River :

ii. Channel :

iii. Tank :

15. Details of Fees paid :

DD No. :

Date :

Bank Name :

Bank Branch :

Amount :

Declaration

I hereby declare that the details and information furnished above are true to the best of my
knowledge and belief and I am aware that if any part of the data/information submitted is found
to be false or misleading at any stage the application will be rejected out rightly. I will forego the
charges and I will not claim the refund of service charges in the case of incorrectness of facts in
the certificates.

AND

I hereby assure that my industry is a non water intensive / water intensive and located in
Safe/Semi-Critical firka. I am applying for Industrial purpose only in the industry premises / by
transport. If the No Objection Certificate is issued for my industry, I will not use the ground water
for any other purpose other than the specified purpose.

(Strike out whichever is not applicable).

Date: Signature of the applicant

Place:
Application for Groundwater Clearance / NOC - List of documents to be enclosed
along with the filled-in 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 5 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. Patta copy
5. Latest Encumbrance Certificate (EC) for last 3 years minimum or more.
6. Land-use Certificate/Undertaking for conversion of land in Ayacut/Residential area.
7. Copy of EB card with tariff paid details (Commercial connection).
8. Annexure I - Items (1) to (4) obtained from the concerned Revenue Inspector (RI).
9. Annexure II - Obtained from concerned Panchayat President/Municipal/Corporation
Commissioner.
10. Annexure III - Certificate of Assurance / Undertaking letter duly signed by the
applicant.
11. Undertaking (Rs.20/- stamp paper) of the applicant regarding the pumping test for
issuing NOC.
12. Indemnity Bond (Rs.100/- stamp paper) duly attested by Notary Public.
13. Demand Draft (Rs.6000/- per Groundwater abstraction structure) in favor of
Executive Engineer, Ground Water Division, Chennai-113.
14. If existing company – Copy of Certificate of Incorporation, Inspector of Factories,
DIC Certificate, ISI Certificate, TNPCB Certificate, Food safety certificate, EB
approval etc., when established.