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2. All wells located on premises connected to a municipal water system shall be abandoned in accordance with the Ch. NR 812, Wis. Adm. Code, no later than one year from the date of connection to a municipal water system, whichever occurs last, unless a well operation permit has been obtained by the well owner from the Village of Elm Grove. If you would like to continue operating your well, providing that the conditions of § 283-5 of the Village of Elm Grove Code of Ordinances are met, you may apply for a well operation permit by visiting the hyperlink.

   Well Abandonment 

   If you plan to abandon your well (i.e. removed from service), it must be properly filled and sealed by a licensed well driller and pump installer. The well must be abandoned in accordance with Wisconsin DNR specifications, specifically NR 812, and a copy of the DNR Filling & Sealing Report (Form 3300-005) must be completed and filed with the Village. Once this has been completed, Please complete this application.

4. First Name of Property Owner(s)*
5. Last Name of Property Owner(s)*
7. Address of Well to be Abandoned*
9. Address Line 2
11. City*
12. State*
13. Zip*
15. Owner Phone Number*
16. Owner Email*
18. Location of Well to be abandoned on Lot*
20. Well Filling and Sealing Report (DNR Form 3300-005)*

    This form will be provided by your licensed well driller and pump installer.

21. Village of Elm Grove Plumbing Permit Application*

    A Well Abandonment Permit also requires a Plumbing Permit Application be completed, found at the hyperlink. Please attach the completed application here. Please write "Well Abandonment Permit" in the Project Description box.

23. The applicant recognizes the following:

    Applicant understands that the permitted work shall comply with all permit provisions and conditions of Elm Grove Code of Ordinances and any special conditions attached hereto, and any plans, details, or notes attached hereto and made a part thereof. Failure to comply with any regulations and/or conditions in this permit will make the permit null and void.

25. Owner Signature*
26. Date*
    Date
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field