Form 7520-1 Permit Review and Issuance

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OMB No. 2040-0042 Form Expires 4/30/07

United States Environmental Protection Agency
Office of Ground Water and Drinking Water
Washington, DC 20460

I. Name and Address of Reporting Agency

United States Environmental Protection Agency

UIC Federal Reporting System

Part I: Permit Review and Issuance/
Wells in Area of Review
(This information is solicited under the
authority of the Safe Drinking Water Act)
II. Date Prepared (month, day, year)

III. State Contact (name, telephone no.)

IV. Reporting Period (month, year)
From

To

October 1, 20
Class and Type of Injection Wells
II
Item
V. Permit
Application

Number of Individual
Permits Issued

B

Existing
Wells

Number of area Permits* Issued

New
Well Field

(Multiple Wells)
(*See instructions on back)

Existing
Well Field

Number of Wells in Area Permits

New
Wells

Issued
C

Permit
Not Issued

D

Modification
Issued

E

2R

2H

III

IV

V

(See B above)

Existing
Wells
Number of Permits Denied/Withdrawn
(after complete technical review)
Number of Major Permit
Modifications Approved

Number of Rule-Authorized
Class II Wells Reviewed

Wells
Reviewed

Number of Wells
A

Wells
VIII.
Area
of
Review
(AOR)

HC

2D

Identified

B

for C/A

New
Wells

(One Well)
Permit

VII.
Permit
File
Review

ER

Number of Permit Applications Received

A

VI.
Permit
Determin­
ation

I

SWD

Wells
Reviewed
Wells
Deficient
Abandoned
Wells

in Area of Review

Other
Wells

Number of Wells Identified

Abandoned
Wells

for Corrective Action

Other
Wells

1. Number of Wells in AOR with
Casing Repaired/Recemented C/A
2. Number of Active Wells in AOR
Plugged/Abandoned

Wells
with
C/A

C

3. Number of Abandoned Wells
in AOR Replugged
4. Number of Wells in AOR with
"Other" Corrective Action

IX. Remarks/Ad Hoc Report

(Attach additional sheets if necessary)

Certification
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any
knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law.
Signature and Typed or Printed Name and Title of Person Completing Form

EPA Form 7520-1 (Rev. 8-01)

Previous edition is obsolete.

Date

Telephone No.

Instructions and Definitions
All reporting is cumulative, year to date, and begins with October 1.
Section V. Permit Application

Well Reviewed: Enter under the appropriate category of injection wells the
number of rule authorized (existing) Class II wells with permit files reviewed
and compliance status determined this year to date.

Enter under each well class the total number of permit applications that have Well Deficient: Enter under the Class II well class the number of reviewed
been received this year to date. Include all applications: complete and rule authorized Class II wells found deficient (not in compliance) that received
incomplete; individual and municipal well (Area Permit); and applications for corrective or enforcement action as appropriate followup response.
“New” and “Existing” wells.
Section VIII. Area of Review (AOR)
A “New Well” is any well other than an existing well or a plugged/abandoned
well that became operable after the effective date of the State(or EPA) Under­ All wells that penetrate the injection zone in the AOR of an injection well/field
ground Injection Control Program.
are reviewed duringpermit determination or duringany AOR analysis of a rule
authorized well file.
An “Existing Well” is any operable (i.e., active, under construction, shut in,
or temporarily abandoned) injection well or a properly plugged and abandoned Item A: Enter under the well class of each permit application or file that has
injection well that was in existence on the effective dateof the State(or EPA) been reviewed this year to date, the number of “Abandoned” and “Other”
UIC Program.
wells reviewed in the AOR.
Section VI. Permit Determination

“Abandoned” includes any well penetratingthe injection zone in theAOR that
has been properly or improperly plugged and/or abandoned. “Other” includes
Permit Determinations include the approval or denial of UIC permit any producing well, operable injection well, dry hole, exploratory well, etc.,
request/actions such as: applications for permits, major modifications to that penetrates the injection zone in the AOR.
issued permits, revocation andreissuanceof permits, or termination of permits
for cause. A complete permit determination includes a thorough technical Corrective Action is required for those wells that penetrate the injection zone
evaluation of the request,public notification or review before issuance, and a in the AOR that are improperly sealed, completed, or abandoned.
final decision document signed by the regulating authority.
Item B: Enter under the well class of each permit applications or file reviewed
Item A: Enter under each well class the number of individual permits issued this year to date, all “Abandoned” and “Other” wells in the AOR that have
required corrective action.
for “New” or “Existing” wells this year to date.
Item B: Enter under each well class the number of area permits that have been
issued for “New” or “Existing” well fields this year to date. (“New” in this
case, describes a nonhazardous injection well field having only new wells or
a mixture of new and existingwells. “Existing” describes a nonhazardous well
field having only existing wells.)

Item C: Enter under the well class of all permit applications or files that have
been reviewed, the number of wells in the AOR which have received corrective
action (be specific) this year to date.

Item C: Enter under each well class the number of “New” and “Existing”
wells covered by the Area Permits entered in Item B.

The public reporting and record keeping burden for this collection of
information is estimated to average 4.5 hours per year. Burden means the total
time, effort, or financial resource 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, processingand maintaininginformation, and disclosing
and providing information; adjust the existing ways to comply with any
previously applicable instructions and requirements;trainpersonnel to be able
to respond to the 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 the use of
automated collection techniques to Director, Collection Strategies Division,
U.S. EnvironmentalProtectionAgency (2822), 1200 Pennsylvania Ave., NW.,
Washington, D.C. 20460. Include the OMB control number in any correspon­
dence. Do not send the completed forms to this address.

Item D: Enter under each well class the number of permits or major modifica­
tions denied by the State(or EPA) UIC program and/or permits withdrawn by
applicants this year to date. The denial of a permit or major modification
should be included as a permit determination only after there has been a
complete technical review.
Item E: Enter under each well class the number of major modifications
approved this year to date. An approved major modification requires a
complete technical review, public notification or review, and a final decision
document signed by the regulating authority.
Section VII. Permit File Review

Paperwork Reduction Act Notice

A complete technical review of an existing (rule authorized) Class II well

record may be conducted by the authorized regulating

authority in lieu of a permit determination in accordance with the

UIC 1425 Guidance to determine whether the well is in compliance with UIC

regulatory requirements. The well record (or file) review may include an

evaluation of siting reports, wells in the area of review, construction, operat­

ing, monitoring or other State reports. Existing Class II wells should be

routinely reviewed at least once every five years during the life of the well.
EPA Form 7520-1 (8-01) Revised