Free DBB-018, Well Owner's Statement and Request to Cancel a Well Permit - Colorado

DBB-018 (05/06) WELL OWNER'S STATEMENT AND REQUEST TO CANCEL A WELL PERMIT COLORADO GROUND WATER COMMISSION Room 818 Centennial Building, 1313 Sherman Street Denver, CO 80203

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 wells located within a Designated Ground Water Basin. I, _________________________________, am the owner of the well with Permit No.____________, located in the __________1/4 of the _________1/4 of Section_________, Township_________, Range_______West of the 6th P.M., and the owner of the land on which this well is located. As owner of this well, I hereby request that the permit for the well be canceled and any water rights associated with this permit and well be abandoned. I understand that this well must be plugged according to the Water Well Construction Rules upon cancellation of the permit and a Well Abandonment Report for the plugged well must be submitted to the Commission, unless the well is permitted for another use. I hereby affirm that I have read and understand the above statement and the information I have provided is true and correct. Signed and dated this ____________ day of _______________________________, 20____________.

Signature of Applicant: ________________________________________________________________ Applicant's Name: Address: City, State & Zip: Telephone No.: ________________________________________________________________
(Please Print)

________________________________________________________________ ________________________________________________________________ ________________________________________________________________