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Elk River ,~,, <br />Municipal Utilities <br />Well Sealing Cost Share Program Application <br />Fill Out Application & turn into Elk River Municipal Utilities Office (ERMU) <br />Include two licensed well sealing contractor bids with your application <br />• Once approved for the Cost Share Program, ERMU will contact you to approve the start of the project <br />• Complete project within (go) days of approval <br />• Submit a copy of the sealed well report available from contractor; and also submit the invoice from <br />your contractor indicating the work performed, with final cost of the project <br />• Once all is submitted you will receive ERMU's portion of the reimbursement within 3o days of project <br />completion and submittal of documents <br />Contact Name: <br />Address: <br />Zip Code: <br />Telephone:, <br />Cell: Email: <br />Property/ParcellD#: <br />WELL SITE ADDRESS: <br />What was/is the well used for? <br />Depth: (ft.) Diameter: (in.) Water Table Depth: <br />Please Check Any That Apply: <br />Is there a septic system? YesNo Are you currently using City water? Yes _No <br />Are other wells nearby?_Yes_No Is the well grouted?_Yes_No <br />Basement offset?_YesNo Are there any fuel tanks?_Yes_No <br />Submit Application to: <br />Elk River Municipal Utilities <br />13069 Orono Parkway NW, P.O. Box 430, Elk River, MN 55330 <br />Office Use: llate Application Approved & Contacted Applicant <br />