This form must be completed in full.  An incomplete or defective application will be returned to the applicant.  Corrections must be submitted to the NRD within 60 days or the application will be canceled.  The District will either issue the permit with conditions attached, or deny the permit, no later than 30 days after receipt of a complete and properly prepared application and application fee.  Read Permit Restrictions here.

Print this form, complete and send it with $17.50 filing fee (payable to the Lower Elkhorn Natural Resources District) to:
Lower Elkhorn Natural Resources District
P.O. Box 1204
Norfolk,  NE  68702-1204

     1. APPLICANT INFORMATION                                            
    NAME:    ______________________________           DWR AND NRD USE ONLY
    ADDRESS:   ____________________________            Late Permit ___
                             ________________________________                Permit No.  LE-_______________
    PHONE:    (____) - _______________________            Registration No._____________

    Applicant is __ landowner, ___tenant, or ___ other (specify)________________
    Application if for __new well construction, or __existing well modification.

2.  PURPOSE OF WELL (select one category)
   __Irrigation  __Domestic  __Livestock  __Public Water Supply
 __Dewatering (0ver 90 days)   __Ground Heat Exchanger
 ___Commercial/Industrial  ___Recovery  ___Ground Water Source Heat Pump
___Monitoring   ___Aquaculture   ___Other (specify)________________________

3.  LOCATION OF THE PROPOSED WELL
   _____________________County,        Township_______North,
  Range______________  __East   ___West,     Section number ____________
The well will be located _____________feet from the ___North   ___South
section line, and will be _____________feet from the ___ East    ____West
section line.

The box at the right represents a one square mile section.  Please indicate in this box:  1.)  The proposed location of the well with an "X", and 2.) the proposed location of the water use area by outlining the area. If the water to be used outside of the above written legal description, give the legal description of this area below: ____________County,  Township__________North, Range______________       ___East  ___West Section Number________________________ If possible, please mark the proposed well site with a flag.

4.  IRRIGATION WELL INFORMATION
    How many acres will be irrigated  __________Acres
    Will a flow meter be used on the proposed new well?   ___Yes     ___No
    What type of irrigation system is planned?   ___Center Pivot   ___Gravity   ___Other(specify)_________
   What type of power supply will be used for the well?   ___Electricity   ___Fuel
    Will the well be used in a system with other wells?    ___Yes   ___No   If yes, how many?_____
    Will fertilizer, chemicals, or animal waste be applied through the irrigation system?_________

5.   REPLACEMENT WELL AND WELL ABANDONMENT INFORMATION
    Is this a replacement well?  ___Yes   ___No  If no, please proceed to section 6.  If yes, you may not need a permit; please contact NRD for clarification.  The following questions are for replacement wells only.  (See note 2 below)
    Registration number of the well to be replaced:_______________.
    Well to be replaced was last operated____________, 19_____.
    Replacement well will be ___________ feet from the original well.
    Original well was decommissioned ______________, 19_____.

6.  EXPECTED SPECIFICATIONS OF THE WELL AND PUMP
     Approximate date when construction will begin:  _____________, 19_____.
      Estimated pump column diameter:  ______ inches.      Estimated total depth of the well:________feet
    Estimated pumping capacity: _________gallons per minute.
      Estimated well casing diameter:  _______inches.
     Please attach test hole log, if available.    Name of Well Driller:______________________

7.  I certify that I am familiar with information contained in this application, and its restrictions, rules, and regulations, and that to the best of my knowledge and belief such information is true, complete, and accurate.

    This form must be completed in full and be accompanied by a nonrefundable, $17.50 filing fee (payable to the Lower Elkhorn Natural Resources District), and submitted to the District at the address listed at top of page.

Date___________________   Signature of Applicant __________________________

Date Approved___________________  NRD Representative______________________

Permit Restrictions

1.  Well permits are required prior to construction or a late fee of $250 will be assessed.

2.  Permits are not required for replacement wells with an intended use of 90 days or less.  A replacement well is a well that replaces an abandoned well within 3 years of the last operation of the abandoned well, and will provide water to the same tract of land.  Section 5 appears above in order to maintain a standard application format for NRD's throughout the state.  Please contact the District if you have questions about this section.

3.  A permit must be obtained for an existing well that did not require a permit, before it is modified into a well that would otherwise require a permit.

4.  If construction of the well is not complete within one year of permit approval, a new permit will be required.  

5.  The well authorized by this permit must comply with well spacing requirements set forth by state statutes.  

6.  Water wells constructed within 50 feet of a stream bank must have a surface water right for that stream from the Nebraska Department of Water Resources before construction of the well.

7.  Any person who commences or causes construction of a well for which the required permit has not been obtained, or who knowingly furnishes false information regarding such permit shall be guilty of Class IV misdemeanor.

8.  This permit does not register the well with the Nebraska Department of Water Resources.  All wells are required to be registered with the Nebraska Department of Water Resources within 30 days after the well is completed.