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DBB-015 (3/01)

REQUEST TO REGISTER IN WATER CONSERVATION PROGRAM COLORADO GROUND WATER COMMISSION Room 818 Centennial Building, 1313 Sherman Street Denver, CO 80203

This form must be complete where applicable. Type or print in BLACK INK. No overstrikes or erasures unless initialed.

NOTE: This form can only be used for large capacity wells located within a Designated Ground Water Basin. Do not use this form for more than one well.

I,

, affirm that I am the present owner of the well with Permit

No. ______________________ located in the _________1/4 of the ________1/4 of Section ________, Township ___________ North/South, Range __________ West of the 6th P.M. I have read the Designated Basin Rule 7.10.4(b) given here and understand the contents thereof. I plan no/low withdrawal of water from the above referenced well during the current calendar year. As owner of this well, I request that water withdrawal during this calendar year be excluded from any future estimate of average annual historic use for this well. I understand that I can not withdraw this request and that this request is valid only for the current calendar year. Signed and dated this ____________________________________________, 20_______. Signature of Well Owner Well Owners Name No. & Street City, State & Zip Telephone No. __________________________________________________ __________________________________________________
Please Print

__________________________________________________ ___________________________________________________ __________________________

Designated Basin Rule 7.10.4(b) reads as follows: 7.10.4(b) Water diversion during the calendar year 1997 and during any successive calendar year may be excluded in computing average annual historic use provided at least ten years of water use information is available to compute historic use and provided a written request to exclude water use for any given calendar year is received by the Commission by May 1 of that calendar year. This written request must be on a form prescribed by the Commission. To avoid having applicants pick and choose water use years during this period to maximize the estimate of average annual historic use, a request to exclude water use for any year once submitted can not be withdrawn.