BOREHOLE REPAIR APPLICATION FORM

Name of village

Name of parish

Name of sub county

Name of district

Name of region

e.g Western, Central, Eastern, Karamoja, West Nile

Distance from nearest water point (In Km)

Expected need/use of the borehole water

Has NHDA drilled any borehole in this district

Expected number of users/beneficiaries for the borehole

Nature of expected users/beneficiaries for the borehole

Name of organization that first drilled the borehole

Cause of the damage

Current problem with the borehole

Borehole Type for which Repair is Requested

Hand dug borehole

Machine dug borehole

If you are human, leave this field blank.

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