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Form must be

complete where

DBB-20 (01/05)

applicable. Type

WELL OWNER'S STATEMENT AND REQUEST TO

or print in BLACK

CANCEL A WELL PERMIT

INK. No

overstrikes or

REPUBLICAN RIVER WATER CONSERVATION DISTRICT (RRWCD)

erasures unless

WATER ACTIVITY ENTERPRISE SUPPLEMENTAL EQIP FUNDING PROGRAM

initialed.

COLORADO GROUND WATER COMMISSION

Room 818 Centennial Building, 1313 Sherman Street, Denver, CO 80203

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:

_______________________________________________________

(Please Print)

Address:

____________________________________________________________

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

Well Owner'S Statement Form And Request To Cancel A Well Permit - Colorado Ground Water Commission