Well Management Section
P.O. Box 64975
St. Paul, Minnesota 55164-0975
651-201-4600 or 800-383-9808
www.health.state.mn.us/divs/eh/wells
Sealing Unused Public Water-Supply Well Grant Application
APPLICANT INFORMATION
Facility Name:
Address:
City:
PWSID No. (if applicable):
County:
ZIP:
Name of the Person who will Serve as the Grantee’s Contact:
Phone:
Fax:
Email:
Federal Tax ID No.:
PERSON AUTHORIZED TO SIGN APPLICATION AND GRANT AGREEMENT ON BEHALF OF THE APPLICANT
Name:
Title:
EXPENDITURE DESCRIPTION
AMOUNTS
Total Cost of the Project
$
Amount Requested from the Minnesota Department of Health (MDH)
($50,000 maximum per grantee)
$
Applicant’s Cost Share (Amount contributed by the Grantee. Must be at least equal
to the amount being requested.)
$
WELL* DOCUMENTATION
Please provide the following information (you may attach other information to describe the location and status of the well).
Minnesota Unique Well Number: ______________________
Well Depth (in feet): ______________________
1.
Well Name: _____________________________________________
Smallest Known Casing Diameter* (in inches): ____________________________
Provide documentation that the well was/is a public water-supply well.*
• Was the well referenced in one or more public water-supply inspection reports that were prepared by MDH?
☐ Yes
☐ No
☐ Unknown
• Is this well included in the Minnesota Drinking Water Information System that is maintained by MDH?
☐ Yes
☐ No
☐ Unknown
• Provide other information that documents that the well was/is a public water-supply well (attach documentation as necessary).
*Term is defined in MDH’s Request for Proposal for the Unused Public Water-Supply Sealing Grant (RFP).
APPLICANT INFORMATION
2. Provide as much of the following information as possible because it is used to score the grant application. Attach information that
you used as documentation for your answers. Check all that apply:
☐ The well connects two or more aquifers.*
☐ The well is a flowing artesian* well.
☐ The well contains contaminants* exceeding federal or state health standards.
☐ The well is located within the inner wellhead management zone* of a public water-supply* well that uses the same aquifer.
☐ The well does not meet the isolation distance* from a potential contamination source as specified in Minnesota Rules, chapter 4725.
☐ The well is located in a groundwater contamination plume* that is designated by the Minnesota Department of Agriculture, the
Minnesota Pollution Control Agency, or MDH.
☐ The well is obstructed or not properly sealed to meet sealing* requirements of Minnesota Rules, chapter 4725.
☐ The well is located within a Special Well and Boring Construction Area* that is designated by MDH.
☐ No grout* was placed in the annular space(s) between the bore hole and the outermost casing,* or between multiple casings.
☐ The well is located within a Drinking Water Supply Management Area* and reaches or penetrates the source water aquifer.
☐ There is additional information that the unused well is a threat to health, safety, or groundwater. (Documentation or an explanation
must be submitted.)
*Term is defined in Request for Proposal (RFP) Well Management Section Unused Public Water-Supply Sealing Grant.
PROJECT DESCRIPTION, BUDGET, AND SCHEDULE
Briefly describe the proposed activities and start/end dates below. Attach a completed MDH Contractor’s Well Sealing Bid Worksheet.
Project Description:
Estimated Start and End Dates:
Start
End
CHECKLIST
☐ I have attached documentation as required under the Well Documentation section, Item 2.
☐ I have filled out all the fields in my application.
☐ I have signed my application.
☐ I have included the MDH Contractor’s Well Sealing Bid Worksheet from at least two MDH licensed well contractors.
☐ I have included a signed statement or acknowledgement stating that the grant applicant has funds available to support its cost share.
2
DISCLAIMER AND SIGNATURE
I certify that the information herein is true and accurate to the best of my knowledge and I submit this application on behalf of the
public water-supply system.
Print Name: _____________________________________________
Signature: ______________________________________________
Date: _______________________________
Note: If you are awarded a grant, no work can begin until all required signatures are obtained on the grant
agreement and the grantee receives a fully executed and signed copy of the grant agreement.
INSTRUCTIONS
You may complete this form manually or electronically. Please print the information if you opt to do this
manually. Once you are finished, submit the Sealing Unused Public Water-Supply Well Grant Application,
Contractor’s Well Sealing Bid Worksheet, and associated documents as indicated below. Questions can be
directed to Nancy La Plante at 651-201-3651.
Option 1 – Mail the application
and associated documents to:
Option 2 – Fax the application
and associated documents to:
Option 3 – Email the application
and associated documents to:
Nancy La Plante
Grant Coordinator
Well Management Section
Minnesota Department of Health
P.O. Box 64975
St. Paul, Minnesota 55164-0975
Nancy La Plante
Grant Coordinator
651-201-4599
[email protected]
If you require this document in another format, call 651-201-4600
or email [email protected].
EHCommon/CWF/WSG/Public/FY 2016-2017/Webpages/Grant Application 2016-2017.docx 10/14/2015R