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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 the municipal water system, whichever occurs last, unless a well operation permit has been obtained by the well owner from the Village of Elm Grove. 

   The Village of Elm Grove may grant a permit to a private well owner to operate a well for a period not to exceed five years, providing the conditions of § 283-5 of the Village of Elm Grove Code of Ordinances are met.

   To submit a Well Operation Permit Application, please complete the following:

4. First Name of Property Owner(s)*
5. Last Name of Property Owner(s)*
7. Address of Well*
9. Address Line 2
11. City*
12. State*
13. Zip*
15. Owner Phone Number*
16. Owner Email*
18. Location of Well on Lot*
20. What is the use of the well water? (Check all that apply)*

    1. Lawn Watering
    2. Garden Watering

    1. Vehicle Washing
    2. Other
22. Safe Water Sample Results by Certified Laboratory*

    To continue utilizing non-potable water from a private well, a safe water sample is required from a WI DNR certified laboratory (may not be more than one year prior to application date). Specifically, the water must be tested for coliform bacteria and E.coli. The DNR's published list of certified laboratories is available at the hyperlink.

23. Village of Elm Grove Plumbing Permit Application*

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

25. The applicant recognizes the following:
    • The granting of this permit does not mean that the Village of Elm Grove has determined the well or water taken from it is safe or in conformity with any rules and regulations thereon.
    • The Village of Elm Grove is not responsible for the maintenance of the well, or for informing the owner of new or existing regulations pertaining thereto.
    • The Village of Elm Grove assumes no liability in regard to monitoring the well or the water taken from it.
    • Once issued, the permit is valid for 5 years. A renewal for the permit may be made, provided that the owner reapplies for the permit prior to the 5-year expiration date. If renewal does not occur, then the well must be abandoned according to Ch. NR 812, Wis. Adm. Code.

    Well and pump installation meet the requirements of Chapter NR812 Wis. Adm. Code and a well constructor's report is on file with the department of natural resources, or certification of the acceptability of the well has been granted by the private water supply section of the department of natural resources.

    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.

27. Applicant Signature*
28. Date*
    Date
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field