W2F051-v5 © The State of Queensland (Department of Natural Resources, Mines and Energy) 2018 Page 1 of 2

Department of Natural Resources, Mines and EnergyABN 59 020 847 551

Application for approval to restrict use of underground water Water Act 2000

Purpose of the form

To allow a water service provider to apply for approval to restrict the use of underground water (other than for stock purposes).

Part A Contact details

Water service provider registration no.:

Specify the full name of the water service provider making this application:

If the applicant is a corporation, please supply the ACN:

Attention (Optional) (e.g. Principal, Secretary, Managing Director, etc.)

Street address:

Mailing address:

Contact details

Title: Mr Mrs Ms Miss Other (specify)

Full name:

Preferred phone: Alternative phone: Facsimile:

Email:

Privacy statement: The information being collected in this request will be used by this department for the purpose of processing your application for approval to restrict use of underground water under section 25ZA of the Water Act 2000. Your personal details will be accessed only by authorised officers within this department and will not be disclosed to any other third party without your consent except where required by law. The information collected will be retained as required by the Public Records Act 2002 and may be stored in a departmental database. More information on the department's privacy commitment can be found on the department’s website at www.business.qld.gov.au.

OFFICE USE ONLY

Application ref. Fee received $

Office Stamp Only

Client ref. Receipt no.

Authorisation ref. Registration date / / Initials

W2F051-v5 © The State of Queensland (Department of Natural Resources, Mines and Energy) 2018 Page 2 of 2

Part B Declaration

All parties to complete and sign the declaration below.

If more signature space is required, copy or print a blank copy of this page, complete and attach. I/We declare that the information in this application is true and correct.

Water service provider Executed for and on behalf of (water service provider)

Water service provider name:

ACN:

By (name): By (name):

Position: Position:

Signature: Signature:

Date: / / Date: / /

Witnessed by: Witnessed by:

Witness signature: Witness signature:

Date: / / Date: / /

Part C Checklist for hydrological report

This form must be accompanied by a brief hydrological report in accordance with the requirements below: Map of the underground area of concern including property boundaries and if applicable or if known, boundaries of the aquifer(s) and / or geological formation(s) containing the aquifer(s).

An estimate of the sustainable yield (in megalitres) of the effected aquifer(s) (if known).

Overview of existing underground works (including number and location) used by the water service provider for their reticulated water supply.

Existing extraction rate (megalitres per day) and monthly volumes (megalitres) currently taken from the aquifer(s) by the water service provider for its reticulated water supply.

Results of bore testing and rends of standing water levels using historical and current records.

An analysis of any previous bore drilling or hydrological reports that may be available for aquifer(s) in the area of concern. (Applicants may request from their local departmental office any bore drilling reports originally submitted to the department.)

Details of current restrictions imposed by the water service provider on existing water service customers.

Assessment of the risks to the reticulated water supply if there is continued use of underground water by persons other than the water service provider.

Any additional information in support of the application.