7520-17 Pre-Closure Notification

Type or print all information. See reverse for instructions

Form Approved 12/99 OMB No. 2040-0214

United States Environmental Protection Agency
UIC Federal Reporting System

Class V Well Pre-Closure Notification Form
1. Name of facility:
Address of facility:
City/Town:

State:

Zip Code:

County:

Location:

Lat./Long.:

State:

Zip Code:

2. Name of Owner/Operator:
Address of Owner/Operator:
City/Town:
Legal contact:

Phone number:

3. Type of well(s):

Number of well(s):

4. Well construction (check all that apply):
Drywell

Septic tank

Cesspool

Improved sinkhole

Drainfield/leachfield

Other

5. Type of discharge:
6. Average flow (gallons/day):

7. Year of well construction:

8. Type of well closure (check all that apply):
Sample fluids/sediments

Clean out well

Appropiate disposal of remaining fluids/sediments

Install permanent plug

Remove well & any contaminated soil

Conversion to other well type

Other (describe):
9. Proposed date of well closure:
10.Name of preparer:

Date:

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 7520-17

Signature

Date Signed

INSTRUCTIONS FOR EPA FORM 7520-17
This form contains the minimum information that you must provide your UIC Program Director if you intend to close your Class V well. This form
will be used exclusively where the EPA administers the UIC Program: AK, AS, AZ, CA, CO, DC, DE, HI, IA, IN, KY, MI, MN, MT, NY, PA, SD, TN, VA, VI,
and on all Tribal Lands. If you are located in a different State or jurisdiction, ask the agency that administers the UIC Program in your State for
the appropriate form.
If you are closing two or more Class V wells that are of similar construction at your facility (two dry wells, for example) you may use one form. If
you are closing Class V wells of different construction (a septic system and a dry well, for example) use one form per construction type.
The numbers below correspond to the numbers on the form.
1.

Supply the name and street address of the facility where the Class V well(s) is located. Include the City/Town, State (U.S. Postal Service
abbreviation) and Zip Code. If there is no street address for the Class V well, provide the route number or locate the well(s) on a map and
attach it to this form. Under "Location," provide the Latitude/Longitude of the well, if available.

2.

Provide the name and mailing address of the owner of the facility, or if the facility is operated by lease, the operator of the facility. Include
the name and phone number of the legal contact for any questions regarding the information provided on this form.

3.

Indicate the type of Class V well that you intend to close (for example, motor vehicle waste disposal well or cesspool). Provide the number
of wells of this well type at your location that will be closed.

4.

Mark an "X" in the appropriate box to indicate the type of well construction. Mark all that apply to your situation. For example, for a septic tank that drains into a drywell, mark both the "septic tank" and "drywell" boxes. Please provide a generalized sketch or schematic of
the well construction if available.

5.

List or describe the types of fluids that enter the Class V well. If available, attach a copy of the chemical analysis results and/or the
Material Safety Data Sheets for the fluids that enter the well.

6.

Estimate the average daily flow into the well in gallons per day.

7.

Provide the year that the Class V well was constructed. If unknown, provide the length of time that your business has been at this location
and used this well.

8.

Mark an "X" in the appropriate box(s) to indicate briefly how the well closure is expected to proceed. Mark all that apply to your situation.
For example, all boxes except the "Remove well & any contaminated soil" and "Other" would be marked if: the connection of an automotive service bay drain leading to a septic tank and drainfield will be closed, but the septic system will continue to be used for washroom
waste disposal only, and the fluids and sludge throughout the system will be removed for proper disposal, the system cleaned, a cement
plug placed in the service bay drain and the pipe leading to the washroom connection, and the septic tank/drainfield remains open for septic use only. In this example, the motor vehicle waste disposal well is being converted to another well type (a large capacity septic system).

9.

Self explanatory.

10.

Self explanatory.

PLEASE READ . . .
The purpose of this form is to serve as the means for the Class V well owner or operator’s notice to the UIC Director of his/her intent to close the
well in accordance with Title 40 of the Code of Federal Regulations (40 CFR) Section 144.12(a). According to 40 CFR §144.86, you must notify the
UIC Program Director at least 30 days prior to well closure of your intent to close and abandon your well. Upon receipt of this form, if the
Director determines that more specific information is required to be submitted to ensure that the well closure will be conducted in a manner that
will protect underground sources of drinking water (as defined in 40 CFR §144.3), the Director can require the owner/operator to prepare, submit
and comply with a closure plan acceptable to, and approved by the Director.
Please be advised that this form is intended to satisfy Federal UIC requirements regarding pre-closure notification only. Other State, Tribal or
Local requirements may also apply.

Paper Work Reduction Act Notice
The public reporting and record keeping burden for this collection of information is estimated to average 1.5 hours per respondent.
Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide
information to or for a Federal agency. This includes the time needed to review instructions, develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and
disclosing and providing information, adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of
information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including thorough the use of automated collection techniques to the Director, Regulatory
information Division, U.S. Environmental Protection Agency (2137), 401 M. Street, S.W., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form 7520-17