FORM -1 A

(Rule - 6)

Application for digging / drilling a well / borewell for agricultural

and Drinking water use

1 Name of the Applicant : Shankar Kulakarni

2 Address of the Applicant : #1035, NS Iyengar Street,

Sheshadripuram, Near
Sheshadripuram College,
Bangalore North-560020

3 Location of proposed borewell, : Plot No: 44

Property / Khatha No. / ward
no. (With complete address & RR Khatha No. 33/44/39
No. of BWSSB water supply/ Ward No: 07, Kempapura,
sanitary connection if any) Hebbal, Yalhanka Hobli.

4 Purpose of digging / drilling well/ : Drinking purpose.

Borewell
(Agricultural/ drinking water use)
Existing status of water supply : BWSSB water supply

5 Distance from existing functional : 550 feet

well/borewell and public borewell

6 Details of payment : Challan Copy enclosed

a) Survey Charges IQs. 50/-
b) Copy of paid challan
c)Branch of Canara Bank
I hereby declare that the above particulars are true to the best of my knowledge and belief.
Place
Date Signature of the Applicant
Note: The amount of Rs.50/- shall be deposited at any branch of CANARA BANK, Bangalore to
the current A/C No.0788201052332 in favour of Karnataka Groundwater Authority (KGA) and
the copy of paid challan has to be enclosed with the application.

(Copies to be enclosed: Khatha Certificate & Tax Paid Receipt)

ACKNOWLEDGEMENT
An application for digging / drilling a new well / borewell for agricultural / drinking water use
is received in this office along with an application fee of Rs.50/- paid at
branch, Canara Bank Dated from Sri/ Smt
Place Signature of Designated Officer
Date Karnataka Ground Water Authority
 FORM - 1B
(Rule-6)
Application for digging/drilling a well/borewell for Domestic/Residential/Industrial/
Commercial/Already Drilled Borewell

1 Name of the Applicant : Shankar Kulakarni

2 Address of the Applicant : #1035, NS Iyengar Street,

Sheshadripuram, Near
Sheshadripuram College,
Bangalore North-560020

3 Location of proposed borewell, : Plot No: 44

Property / Khatha No. / ward
no. (With complete address & RR Khatha No. 33/44/39
No. of BWSSB water supply/ Ward No: 07, Kempapura,
sanitary connection if any) Hebbal, Yalhanka Hobli.

4 Purpose of digging / drilling well/ : Drinking purpose.

Borewell
(Agricultural/ drinking water use)
Existing status of water supply : BWSSB water supply

5 Distance from existing functional : 550 feet

well/borewell and public borewell

6 Details of Charges : Challan Copy enclosed

a) Survey Charges Rs. 500/-
b) Original paid challan
c) Branch of Canara Bank

7 Ph.No:-

I hereby declare that the above particulars are true to the best of my knowledge and belief

Place:
Date: Signature of the Owner

NOTE: The amount ofRs.500/- shall be deposited at any branch of CANARA BANK, Bengaluru to the
Current A/c. No.0788201052332 in favour of KARNATAKA GROUNDWATER AUTHORITY (KGA)
and the Original Paid Challan has to be enclosed with the application.

(Copies to be enclosed: Khata Certificate, BBMP Tax Paid Receipt, Sale Deed & Self Addressed Post
Card)
 ACKNOWLEDGEMENT
An application for digging / drilling a new well / borewell for Residential, Industrial, Commercial,
Domestic or other use purpose is received in this office along with an application of Rs.500/- paid at ------
-- branch, Canara Bank
Dated: from Sri/Smt----------------------------

Place: Signature of Designated Officer

Date: Karnataka Ground Water Authority