Print the following form and send to the Lower Elkhorn NRD.  The address is below.

Company__________________________________

Address___________________________City/State________________________

Phone____________________________

Cost Share Components:

____cy chlorinated fill sand and/or gravel	$______/cy	$________
____bags (50 lbs) bentonite/hole plug	$______/bag	$________
____cy concrete	$______/cy	$________
Miscellaneous (please itemize labor, mileage, etc.)		$________
Total of Cost Shareable Components		$________
Non cost Share Components (Landowner's Own Cost):
Removal of above ground obstacles if necessary (windmill tower, concrete cover, etc.)		$________
Removal of obstacles in the well (pump rods, submersible pump, etc.)		$________
Well Sealer Signature__________________________________________________

Print and mail to:
Lower Elkhorn Natural Resources District
P.O.  Box 1204
601 East Benjamin Avenue
Lifelong Learning Center
Norfolk,  NE  68702-1204
Phone:  402-371-7313  Fax:  402-371-0653