LBBNRD...Water Well Construction Permit

This form must be completed in full and be accompanied by a non-refundable $50.00 filing fee (payable to the Lower Big Blue Natural Resources District). Forward this application and filing fee to: Lower Big Blue NRD, 805 Dorsey Street, PO Box 826, Beatrice, NE 68310-0826, phone: 402-228-3402.

Please take the time and fill out the information correctly. An incomplete or defective application will be returned by the District, with 60 days being allowed for resubmission. All permits shall be issued by the District with the conditions attached, or denied no later than 30 days after receipt of a complete and properly prepared application.

1. NAME AND ADDRESS OF APPLICANT:

__________________________________________

DWR & NRD USE ONLY

Permit No. LBB-________________

Reg. No. ______________________

Phone ( ) _______-___________

2. PURPOSE OF WELL (indicate one): ( ) Irrigation      ( ) Domestic       ( ) Livestock       ( ) Public Water Supply
( ) Dewatering (over 90 days)                ( ) Geothermal   ( ) Ground Heat Exchange             ( ) Industrial
( ) Recovery       ( ) Ground Water Source Heat Pump   ( ) Monitoring   ( ) Aquaculture ( ) Other

3. IDENTIFY THE LOCATION OF THE PROPOSED WELL:
___________________________________________ County,
Township _______, North, Range ________ East, Section _________

The box at the right represents one square mile, (section). Indicate with an "X", the proposed location of the well. Outline the proposed water use area, if water is to be used outside the above written legal description, give legal description of water use area.

Township ________ North, Range ________ East, Section _______

The well will be located _______ feet from the North/South section line, and will be _______ feet from the East/West section line.

1 m i l e			NWNW	NENW	NWNE	NENE
			SWNW	SENW	SWNE	SENE
	1/2 mi.		NWSW	NESW	NWSE	NESE
	1/2 mi.	1/4 mi.	SWSW	SESW	SWSE	SESE
			1320'
			2640'
			5280'

4. IRRIGATION WELLS
How many acres will be irrigated? _________
Will flow meter be used on proposed new well?   (   ) Yes         (   ) No
Type of irrigation system:      (   ) Center pivot      (   ) Gravity   (   ) Other (specify) __________________________
Will system be: (   ) Electric   (   ) Fuel powered?
Will the well be used in a system with other wells? (    ) Yes   (   ) No    How many ____________________
Will fertilizer, chemicals, or animal waste be applied through the system?    (   ) Yes    (   ) No

5. REPLACEMENT AND ABANDONMENT WELL INFORMATION
A. Is this a replacement well? ( ) Yes ( ) No
B. Registration number of well to be replaced: __________________________________________
C. Well to be replaced was last operated: ______________________________________, _______ (year)
D. Replacement well is ____________________ feet from original well.
E. Completion of original well decommissioning on _________________________________, _______ (year)
F. Will new well water the same tract of land as the decommissioned well? ( ) Yes ( ) No

6. SPECIFICATIONS OF INTENDED WELL AND PUMP:
Approximate date when construction will begin: ____________________________________, ________ (year)
Estimated total well depth ________ feet. Estimated water well capacity: ________ gallons per minute
Pump column diameter: _________ inches. Well casing diameter: _________ inches
Please attach test hole log, if available. Name of well driller: __________________________________________

7. I certify that I am familiar with the information contained in this application, and it's restriction, rules and regulations 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 non-refundable $50.00 filing fee (payable to the Lower Big Blue Natural Resources District), 805 Dorsey Street, PO Box 826, Beatrice, NE 68310-0826. Phone: 402-228-3402

Date: ________________ Signature of Applicant: ________________________________________________

Date Approved: ___________ Date Denied: __________ NRD Representative: _________________________