7520-9 Completion Form for Injection Wells

OMB No. 2040-0042

Approval Expires 4/30/07

United States Environmental Protection Agency
Washington, DC 20460

Completion Form For Injection Wells
Administrative Information
1. Permittee

Address

(Permanent Mailing Address) (Street, City, and ZIP Code)

2. Operator

Address

(Street, City, State and ZIP Code)

3. Facility Name

Address

Telephone Number

(Street, City, State and ZIP Code)

4. Surface Location Description of Injection Well(s)
State

County

Surface Location Description
____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

Section ____ Township ____ Range ____

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface
Location ____ ft. frm (N/S) ____ Line of quarter section
and ____ ft. from (E/W) ____ Line of quarter section.
Well Activity

Well Status

Type of Permit

____ Class I

____ Operating

____ Individual

____ Class II

____ Modification/Conversion

____ Area : Number of Wells ____

____ Brine Disposal

____ Proposed

____ Enhanced Recovery
____ Hydrocarbon Storage
____ Class III
____ Other
Lease Number _______________

Well Number _______________

Submit with this Completion Form the attachments listed in Attachments for Completion Form.

Certification
I certify under the penalty of law that I have personally examined and am familiar with the information submitted in
this document and all attachments and that, based on my inquiry of those individuals immediately responsible for
obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are
significant penalties for submitting false information, including the possibility of fine and imprisonment. (Ref. 40 CFR 144.32)

Name and Official Title (Please type or print)

EPA Form 7520-9 (Rev. 8-01)

Signature

Date Signed

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respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection
Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send
the completed forms to this address.

Attachments to be submitted with the Completion report:
I. Geologic Information

4. Provide data on centralizers to include number, type
and depth.

1. Lithology and Stratigraphy
5. Provide data on bottom hole completions.
A. Provide a geologic description of the rock units pene­

trated by name, age, depth, thickness, and lithology of

each rock unit penetrated.

6. Provide data on well stimulation used.
III. Description of Surface Equipment

B. Provide a description of the injection unit.

(1) Name

(2) Depth (drilled)

(3) Thickness

(4) Formation fluid pressure

(5) Age of unit

(6) Porosity (avg.)

(7) Permeability

(8) Bottom hole temperature

(9) Lithology

(10) Bottom hold pressure

(11) Fracture pressure

C. Provide chemical characteristics of formation fluid
(attach chemical analysis).
D. Provide a description of freshwater aquifers.

(1) Depth to base of fresh water (less than 10,000 mg/l

TDS).

(2) Provide a geologic description of aquifer units with

name, age, depth, thickness, lithology, and average total

dissolved solids.

1. Provide data and a sketch of holding tanks, flow lines,
filters, and injection pump.
IV. Monitoring Systems
1. Provide data on recording and nonrecording injection
pressure gauges, casing-tubing annulus pressure
gauges, injection rate meters, temperature meters, and
other meters or gauges.
2. Provide data on constructed monitor wells such as
location, depth, casing diameter, method of cementing,
etc.
V. Logging and Testing Results
Provide a descriptive report interpreting the results of
geophysical logs and other tests. Include a description
and data on deviation checks run during drilling.
VI. Provide an as-built diagrammatic sketch of the injec­
tion well(s) showing casing, cement, tubing, packer, etc.,
with proper setting depths. The sketch should include
well head and gauges.

II. Well Design and Construction
1. Provide data on surface, intermediate, and long string
casing and tubing. Data must include material, size,
weight, grade, and depth set.
2. Provide data on the well cement, such as type/class,
additives, amount, and method of emplacement.
3. Provide packer data on the packer (if used) such as
type, name and model, setting depth, and type of annular
fluid used.

EPA Form 7520-9 Reverse

VII. Provide data demonstrating mechanical integrity
pursuant to 40 CFR 146.08.
VIII. Report on the compatibility of injected wastes with
fluids and minerals in both the injection zone and the
confining zone.
IX. Report the status of corrective action on defective
wells in the area of review.
X. Include the anticipated maximum pressure and flow
rate at which injection will operate.