Free DBB-20,WELL OWNER'S STATEMENT AND REQUEST TO CANCEL A WELL PERMIT (EQIP Funding) - Colorado

DBB-20 (01/05) WELL OWNER'S STATEMENT AND REQUEST TO CANCEL A WELL PERMIT REPUBLICAN RIVER WATER CONSERVATION DISTRICT (RRWCD) WATER ACTIVITY ENTERPRISE SUPPLEMENTAL EQIP FUNDING PROGRAM 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 should only be used for wells located within the Republican River Basin and the Northern High Plains Designated Ground Water Basin that are enrolling in the RRWCD Water Activity Enterprise Supplemental EQIP Funding Program.

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, conditional on the final acceptance of this permit in the RRWCD Water Activity Enterprise Supplemental EQIP Funding Program, that the permit for the well be cancelled 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.

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: _______________________________________________________ (Please Print) ____________________________________________________________ _______________________________________________________

City, State & Zip:

Telephone No.:_______________________________________________________________ For RRWCD Water Activity Enterprise Use Only: I, _________________________________, as the program administrator, acknowledge that the subject water right has been accepted into the RRWCD Water Activity Enterprise Supplemental EQIP Funding Program. 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 Program Administrator_______________________________________________________ Upon completion by RRWCD Water Activity Enterprise, send form to Colorado Ground Water Commission