Print the following form and send to:
Lower Elkhorn Natural Resources District
P.O.  Box 1204
601 East Benjamin Avenue
Lifelong Learning Center
Norfolk,  NE  68702-1204
You will also need the Well Sealer Quote Form

Landowner:___________________________________

Address:_____________________________________

City/State:____________________________________

Phone:_____________________Social Security Number:______________________

Well Information:
Location:     County:__________________________
Quarter_______________ Section____________________
Township_____________ Range______________________

Site Description:

(Attach map with well plotted and mail to Lower Elkhorn NRD)

Is the well registered? ___ Yes ___ No
Type:   ___Irrigation  ___  Domestic ___Stock ___Other ___Hand dug
Depth:___________   Inside Casing Diameter __________

Pump Attached?   ___ No   ___Yes    Well Pit Size___________
Casing: __Tile  ___ Transit ___PVC  ___Steel   ___Brick  ___Concrete ___Unknown
Obstructions over well?   ___ None ___Windmill  ____Well house
____Fences ____ Stock Tank ____Concrete Pad  ___Other

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