Appendix E - Reporting Forms

0370supp25 Appendix E - Forms.pdf

Underground Injection Control (UIC) Program (Renewal)

Appendix E - Reporting Forms

OMB: 2040-0042

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APPENDIX E

APPENDIX E
Underground Injection Control Program Reporting Forms

Number

Form

7520-1
7520-2A
7520-2B
7520-3
7520-4
7520-6
7520-7
7520-8
7520-9
7520-10

Permit Review and Issuance/Wells in Area of Review
Compliance Evaluation
Compliance Evaluation - Significant Noncompliance
Mechanical Integrity Test/Remedial Actions
Quarterly Exceptions List
UIC Permit Application
Application to Transfer Permit
Injection Well Monitoring report
Completion Form for Injection Wells
Completion Report for Brine Disposal, Hydrocarbon Storage, or Enhanced
Recovery Well
Annual Disposal/Injection Well Monitoring Report
Well Rework Record
Plugging and Abandonment Plan
Inventory of Injection Wells
Pre-Closure Notification Form

7520-11
7520-12
7520-14
7520-16
7520-17

Please type or print all information. Please read instructions.

OMB No. 2040-0042 Form Expires 11/30/2014

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)
To

From

October 1, 20

Class and Type of Injection Wells
II
Item
V. Permit
Application

Number of Individual
Permits Issued
(One Well)
Permit

Number of area Permits* Issued
B

Permit
Not Issued

Modification
Issued

III

Wells
Identified
for C/A

Existing
Wells
New
Well Field
Existing
Well Field

Number of Wells in Area Permits

New
Wells

(See B above)

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Number of Permits Denied/Withdrawn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

Class II Wells Reviewed

Reviewed

New
Wells

(*See instructions on back)

Number of Rule-Authorized

Wells

VIII.
Area
of
Review
(AOR)

(Multiple Wells)

Issued
C

VII.
Permit
File
Review

Number of Permit Applications Received

VI.
Permit
Determination

SWD

Number of Wells

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
Wells
with
C/A

2. Number of Active Wells in AOR
Plugged/Abandoned
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. 12-11)

Previous edition is obsolete.

Date

Telephone No.

Instructions and Definitions
All reporting is cumulative over the federal fiscal year, and
includes activities from October 1- September 30. Please do not
leave anything blank on this form. Enter a 0 if there are no
wells that apply to the information requested; enter “NA” if
the information does not apply to your program (e.g., if you do
not oversee that class of well).

Wells Reviewed: For rule authorized (existing) Class II wells only,
enter the number of wells with permit files reviewed and
compliance status determined this federal fiscal year to date.
Wells Deficient: For rule authorized Class II wells, enter the
number of reviewed wells that were found deficient (not in
compliance with UIC regulations).

Section V. Permit Application
Section VIII. Area of Review (AoR)
Enter, under each well class, the total number of permit
applications that have been received this year to date. Include all
applications regardless of their status for “New” and “Existing”
wells.

All wells that penetrate the injection zone in the AoR of an injection
well/field are reviewed during permit determination or during any
AoR analysis of a rule authorized well file.

A “New Well” is any well that began operation after the effective
date of the State (or EPA) Underground Injection Control
Program.

Item A: For each well class, enter the number of “Abandoned” and
“Other” wells reviewed in the AoR for each permit application or
file that has been reviewed this federal fiscal year to date.

An “Existing Well” is any injection well that was in existence on
the effective date of the State (or EPA) UIC Program.

“Abandoned” includes any well penetrating the injection zone in the
AoR that has been properly or improperly plugged and/or
abandoned.

Section VI. Permit Determination
Permit Determinations include the approval or denial of UIC
permit requests/actions such as: applications for permits, major
modifications to issued permits, revocation and reissuance of
permits, or termination of permits for cause. A complete permit
determination includes a thorough technical evaluation of the
request, public notification or review before issuance, and a final
decision document signed by the regulating authority.
Item A: For each well class, enter the number of individual
permits issued for “New” or “Existing” wells this federal fiscal
year to date.
Item B: For each well class, enter 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 existing wells.
“Existing” describes a nonhazardous well field that has existing
wells only.)
Item C: For each well class, enter the number of “New” and
“Existing” wells covered by the Area Permits entered in Item B.
Item D: For each well class, enter the number of permits or major
modifications denied by the UIC primacy program and/or permits
withdrawn by applicants this federal fiscal 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: For each well class, enter the number of major modifications approved this federal fiscal 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
A complete technical review of an existing (rule authorized) Class
II well record may be conducted to determine whether the well is
in compliance with UIC regulatory requirements in lieu of a permit
determination. The well record (or file) review may include an
evaluation of siting reports, wells in the area of review,
construction, operating, monitoring or other reports. Existing Class
II wells should be routinely reviewed at least once every five years
during the life of the well.

“Other” includes any producing well, operable injection well, dry
hole, exploratory well, etc., that penetrates the injection zone in the
AoR.
Corrective Action is required for those wells that penetrate the
injection zone in the AoR that are improperly sealed, completed, or
abandoned.
Item B: For each well class, enter the number of “Abandoned” and
“Other” wells in the AoR that have required corrective action for
each permit application or file reviewed this federal fiscal year to
date.
Item C: For each well class, enter the number of wells in the AoR
which have received corrective action (be specific) for all permit
applications or files that have been reviewed this year to date.
Paperwork Reduction Act Notice
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, 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 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. 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.

EPA Form 7520-1 (11-14) Revised

Please type or print all information. Please read instructions on rever se.
United States Environmental Protection Agenc y
Office of Ground Water and Drinking Water
Washington, DC 20460

OMB No. 2040-0042

Approval Expires 11/30/2014

I. Name and Address of Reporting Agency

United States Environmental Protection Agency

UIC Federal Reporting System

Part II: Compliance Evaluation
(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)
To

From

October 1, 20

Class and Type of Injection Wells
II
Item
Total
Wells

III

Number of Unauthorized
Injection Violations

2. Number of Mechanical Integrity Violations

Summary
of

Number of Wells with Violations
1.

SWD

Total
Violations

Violations

3. Number of Operation and
Maintenance Violations
4. Number of Plugging
and Abandonment Violations
5. Number of Monitoring and
Reporting Violations
6. Number of Other Violations
(Specify)

Total
Wells

Number of Wells with
Enforcement Actions
1. Number of Notices of Violation
2. Number of Consent Agreements

VI.

3. Number of Administrative Orders

Summary
of
Enforcement

Total
Enforcement

Actions

4. Number of Civil Referrals
5. Number of Criminal Referrals
6. Number of Well Shut-ins
7. Number of Pipeline Severances
8.

VII.
Summary
of
Compliance

Number of Other Enforcement Actions
(Specify)

Number of Wells
Returned to Compliance

A. This Quarter
B. This Year

VIII.
Number of Cases of Alleged Contamination of a USDW
Contamination
IX.
MIT Resolved

Percent of MIT Violations Resolved in 90 Days

X. Remarks/Ad Hoc Report (Attach additional sheets)
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 7520-2A ( 12-11)

Replaces EPA Form 7520-2 which is obsolete

Date

Telephone No.

Definitions and Instructions
All reporting is cumulative over the federal fiscal year, and includes
activities from October 1- March 31 (for midyear reporting) and from
October 1- September 30 (for end of year reporting). Please do not
leave anything blank on this form. Enter a 0 if there are no wells
that apply to the information requested; enter “NA” if the
information does not apply to your program (e.g., if you do not
oversee that class of well).
A Class I, II, III, IV, or V injection well with a violation of a permit or
rule requirement is said to be in noncompliance. Note: A well with
certain types of violations may also be in significant noncompliance.
(See Form 7520-2B (Reverse) for definitions of SNC violations.)
Section V. Summary of Violations
(Includes all noncompliance, significant and non-significant)
A. Total Wells: For each well class, enter the number of wells with
one or more violations in this federal fiscal year to date. Enter each
well only once. Include all wells with violations, even those with
violations that have been returned to compliance.
B. Total Violations:
Items 1-6: For each well class, enter the number of times each
violation type has been identified this federal fiscal year to date.
Section VI. Summary of Enforcement
A. Total Wells: For each well class, enter the number of wells with
violations that have been addressed by the specific type of
enforcement action indicated in the row, in this federal fiscal year to
date. Enter each well only once.
B. Total Enforcement Actions:
Items 1-8: For each well class, enter the number of times wells with
violations been addressed by the specific type of enforcement action
indicated in the row, in this federal fiscal year to date. (Count draft and
final Administrative Orders together.)
Section VII. Number of Wells Returned to Compliance
A “Well Returned to Compliance” is a well that has all underlying
violations resolved and compliance has been verified by the primacy
program. Note: An enforcement action alone (e.g., well shut-in) does
not constitute a “return to compliance;” however, plugging and
abandonment does constitute a return to compliance.
A. For each well class, enter the number of wells returned to
compliance in the current quarter only.
B. For each well class, enter the number of wells returned to
compliance this federal fiscal year to date. Enter each well only
once.
Section VIII. USDW Contaminations
For each well class, enter the number of times a well in noncompliance
has allegedly contaminated an underground source of drinking water
(USDW) this federal fiscal year to date.

Section IX. Percent of MIT Violations Resolved in 90 Days
For each well class, enter the percentage of MIT violations resolved
within 90 days as of the end of the reporting period.

Mechanical Integrity violations are as defined in Section V, under
“Mechanical Integrity.”

Resolved is defined as returned to compliance (per Section VII).

MI violations not associated with loss of mechanical integrity
(such as reporting) are not counted under this section.

Violations occurring WITHIN 90 days of September 30 should
be included in reporting for the following federal fiscal year.
To calculate the percentage:

Add up the total number of MIT violations that occurred within
the year prior to the reporting cutoff.

Add up the number of these violations that were resolved within
90 days as of 3/31(for midyear reporting) or as of 9/30 (for end of
year reporting).

Calculate the percentage of total MIT violations that were
resolved in 90 days or less.
Example for Midyear reporting:

Number of violations that occurred from 7/1 – 3/31 = 8

Number of these violations resolved within 90 days as of 3/31 = 2

Percentage of MIT violation resolved within 90 days = 25%
Example for End of Year reporting:

Number of MIT violations that occurred from 7/1 – 6/30 = 10
o 8 from midyear plus 2 additional (4/1 to 6/30)


Number of these violations resolved within 90 days as of 9/30 = 5
o 2 (from midyear) + 3 (from 4/1 to 6/30)



Percentage of MIT resolved within 90 days by 9/30 = 50%

Paperwork Reduction Act
The public reporting and record keeping burden for this collection of
information is estimated to average 6 hours per response. 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, 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 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.
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.
EPA Form 7520-2A (11-14) Revised

Please type or print all information. Please read instructions on reverse.
United States Environmental Protection Agency
Office of Ground Water and Drinking Water
Washington, DC 20460

OMB No. 2040-0042

Approval Expires 11/30/2014

I. Name and Address of Reporting Agency

United States Environmental Protection Agency

UIC Federal Reporting System

Part II: Compliance Evaluation
Significant Noncompliance
(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)
To

From

October 1, 20

Class and Type of Injection Wells
II
Item
Total
Wells

Number of Wells with SNC Violations

1. Number of Unauthorized
Injection SNC Violations
2. Number of Mechanical Integrity
SNC Violations
3. Number of Injection Pressure
SNC Violations
4. Number of Plugging
and Abandonment SNC Violations
5. Number of SNC Violations
of Formal Orders
6. Number of Falsification
SNC Violations
7. Number of Other SNC Violations
(Specify)

Number of Wells with
Enforcement Actions Against SNC

V.
Summary
of
Significant

Total

Non-

Violations

Compliance
(SNC)

Total
Wells

III

3. Number of Administrative Orders
Total
Enforcement
Actions

Against

4. Number of Civil Referrals
5. Number of Criminal Referrals
6. Number of Well Shut-ins

SNC

7. Number of Pipeline Severances
8.

VII.
Summary
of
Compliance

2. Number of Consent Agreements/Orders

Summary

Enforcement

1. Number of Notices of Violation

VI.

SWD

Number of Other Enforcement Actions
Against SNC Violations (Specify)

Number of Wells in SNC
Returned to Compliance

A. This Quarter
B. This Year

VIII.
Number of Cases of Alleged Contamination of a USDW
Contamination
IX.
Well
Closure

Class IV/Endangering Class V
Well Closures

Involuntary Well Closure
Voluntary Well Closure

EPA Form 7520-2B ( 12-11)

Replaces EPA Form 7520 -2 which is obsolete.

Date

Telephone No.

Instructions and Definitions
Section IV. Reporting Period: All reporting is cumulative over the
federal fiscal year, and includes activities from October 1- March 31 (for
midyear reporting) and from October 1- September 30 (for end of year
reporting).
Please do not leave anything blank on this form. Enter a 0 if there are
no wells that apply to the information requested; enter “NA” if the
information does not apply to your program (e.g., if you do not oversee
that class of well).
Note: Significant Noncompliance violations are a subset of the violations
reported on EPA Form 7520-2A.
Definitions of SNC Violations: SNC violations are violations that
endanger or pose a significant potential to endanger underground sources
of drinking water (USDWs), and violations that are not addressed after
enforcement actions. For example:
1. The following violations for a Class I well:
a. Contamination of a USDW;
b. Injection of unauthorized fluid(s);
c. Injection into unauthorized zones;
d. Failure to cease injection after loss of MI detected; Failure to
comply with corrective action requirements;
e. Failure to operate automatic shutdown system;
f. Failure to operate automatic warning system;
g. Unauthorized plugging and abandonment;
h. Violation of a Formal Order;
i. Knowing submission of false information;
j. Violations involving loss of mechanical integrity;
k. Violations of maximum injection pressure;
l. Failure to install and/or operate injection pressure and annulus
pressure monitoring systems or other monitoring systems, required
by permit or rule; and
m. Failure to maintain required annulus pressure.
Also, any Class I well with a non-SNC violation that is noted three times
within twelve months of the first violation is considered to be in SNC.
2. The following violations for a Class II, III, or V well:
a. Unauthorized Injection – Any unauthorized emplacement of fluids
(where formal authorization is required);
b. Mechanical Integrity – Well operation without mechanical integrity
which causes the movement of fluid outside the authorized zone – if
injection of such fluid may have the potential for endangering a
USDW;
c. Injection Pressure – Well operation at an injection pressure that
exceeds the permitted or authorized injection pressure and causes
the movement of fluid outside the authorized zone of injection – if
such movement may have the potential for endangering a USDW;
d. Plugging and Abandonment – The plugging and abandonment of an
injection well in an unauthorized manner. These wells are in SNC
only when there is endangerment of USDW and there is an
identifiable owner/operator;
e. Violation of a Formal Order – Any violation of a formal
enforcement action, including an administrative or judicial order,
consent agreement, judgment, or equivalent action; or
f. Falsification – The knowing submission or use of any false
information in a permit application, periodic report or special
request for information about a well.
3. Any violation for a Class IV well.
EPA Form 7520-2B (11-14) Revised

Section V. Total No. of Wells with SNC Violations: Significant
Noncompliance violations are a subset of the violations reported on EPA
From 7520-2A. For each well class, enter the number wells with SNC
violations identified in the federal fiscal year to date. Report the well even
if the violation has been corrected. Count each well only once.
For each well class in subsections 1 through 7, enter the number the number
of times each SNC violation has been identified this federal fiscal year to
date.
Section VI. Total SNC Enforcement Actions: Significant Noncompliance violations are a subset of the violations reported on EPA Form
7520-2A. For each well class, enter the number of wells with SNC
violations that have received an enforcement action(s) this year to date.
Report the well even if the violation has been corrected. Count each well
only once.
For each well class in subsections 1 through 7, enter the number of times
wells with SNC violations have received each type enforcement action this
federal fiscal year to date.
Section VII. No. of Wells Returned to Compliance: “Well Returned to
Compliance” is a well that has all underlying violations resolved and
compliance has been verified by the primacy program. Note: an
enforcement action alone (e.g., well shut-in) does not constitute a “return
to compliance;” however, plugging and abandonment does constitute a
return to compliance.
For each well class in subsection A, enter the number of wells returned to
compliance (as a result of an enforcement action against a SNC violation).
For each well class in subsection B, enter the number of wells returned to
compliance (as a result of an enforcement action against an SNC violation)
this federal fiscal year to date. Enter each well only once.
Section VIII. USDW Contaminations: For each well class, enter the
number of times a well in SNC has allegedly contaminated a USDW this
federal fiscal year to date.
Section IX. Number of Class IV/V Endangering Class V Well Closures: For Class IV and Class V wells, enter the number of voluntary or
involuntary well closures.
Voluntary well closure means well closed as a direct result of outreach
activities.
Involuntary well closure means wells closed as a result of enforcement
actions or permit call-ins.
Well closure describes a process to permanently discontinue injection in
accordance with the UIC regulations.
Paperwork Reduction Act
The public reporting and record keeping burden for this collection of information is
estimated to average 5.5 hours per response. 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, 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 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. Environmental Protection Agency (2822), 1200 Pennsylvania
Ave., NW., Washington, DC 20460. Include the OMB control number in any
correspondence. Do not send the completed forms to this address.

Please type or print all information. Please read instructions on reverse.
United States Environmental Protection Agency
Office of Ground Water and Drinking Water
Washington, DC 20460

OMB No. 2040-0042

Approval Expires 11/30/2014

I. Name and Address of Reporting Agency

United States Environmental Protection Agency

UIC Federal Reporting System

Part III: Inspections
Mechanical Integrity Testing
(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)
To

From

October 1, 20

Class and Type of Injection Wells
II
Item
Total
Wells

V.
Summary
of

Total
Inspections

Inspections

Total
Wells

A
B

For
Significant

Leak

Mechanical
Integrity
(MI)

For
Fluid

Migration

Total
Wells

VII.
Summary
of
Remedial
Action

III

Number of Wells Inspected
1. Number of Mechanical Integrity Tests
(MIT) Witnessed
2. Number of Emergency Response or
Complaint Response Inspections
3. Number of Well
Constructions Witnessed
4. Number of Well
Pluggings Witnessed
5. Number of Routine/Periodic
Inspections
Number of Wells Tested or Evaluated
for Mechanical Integrity (MI)
No. of Rule-Authorized Wells Passed 2-part test
Tested/Evaluated for MI
Failed 2-part test
Well Passed
1. Number of Annulus Pressure
Monitoring Record Evaluations Well Failed

VI.
Summary

SWD

Total
Remedial
Actions

VIII. Remarks/Ad Hoc Report

2. No. of Casing/
Tubing Pressure Tests

Well Passed

3. Number of Monitoring
Record Evaluations

Well Passed

4. No. of Other Significant Leak
Tests/Evaluations (Specify)

Well Passed

1. Number of Cement
Record Evaluations

Well Passed

2. Number of Temperature/
Noise Log Tests

Well Passed

3. No. of Radioactive Tracer/
Cement Bond Tests

Well Passed

4. No. of Other Fluid Migration
Tests/Evaluations (Specify)

Well Passed

Well Failed

Number of Wells with
Remedial Action
1. Number of Casing Repaired/
Squeeze Cement Remedial Actions
2. Number of Tubing/Packer
Remedial Actions
3. Number of Plugging/Abandonment
Remedial Actions
4. Number of Other Remedial Actions
(Specify)

(Attach additional sheets)

EPA Form 7520-3 (Rev. 12-11)

Previous edition is obsolete.

Date

Telephone No.

Item C: Significant Leak Tests: (This year to date)
Items 1-4: For each well class, enter the number of times wells
have passed or failed a field test/record evaluation for significant
leaks.
Item D: Fluid Migration Tests (this federal fiscal year to date):

Section V. Summary of Inspections
A complete inspection should include an assessment of: the well
head, pressure and flow meters, pipeline connections, and any
other equipment associated with the injection system. An
inspection is complete only when a report has been filed with the
primacy agency.
Item A: For each well class, enter the number of wells that have
been inspected as of the end of the reporting period. Enter each
well only once.

Items 1-4: For each well class, enter the number of times wells
have passed or failed a field test/record evaluation for fluid
migration.
Section VII. Summary of Remedial Action
A failure of mechanical integrity (MI) may occur at any time
during the life of an injection well. Failure may be identified
during an inspection, a field test, an evaluation of well records, or
during routine operation of a well. Remedial actions include
additional permit conditions, monitoring, or testing.

Total Inspections (this federal fiscal year to date):
Item 1: For each well class, enter the number of inspections to
witness field Mechanical Integrity Tests. (At least 25% of MITs
performed by operators each year should be witnessed.)

Item A: For each well class, enter the number of wells that have
received remedial actions this federal fiscal year to date. Enter
each well only once.
Total Remedial Actions: (this federal fiscal year to date):

Item 2: For each well class, enter the number of inspections that
have been in response to a problem reported to the regulating
authority.
Item 3: For each well class, enter the number of inspections of
well constructions or any preoperational activities.
Item 4: For each well class, enter the number of inspections of
plugging and abandonment.
Item 5: For each well class, enter the number of inspections that
have been routine / periodic.
Section VI. Summary of Mechanical Integrity
A complete MIT is composed of a test for significant leaks in the
casing, tubing or packer and a test for significant fluid migration
into a USDW through vertical channels adjacent to the well bore.
An MIT consists of a field test on a well or an evaluation of a
well’s monitoring records (i.e., annulus pressure, etc.) or cement
records. At a minimum, the mechanical integrity of a Class I, II,
or III (solution mining of salt) well should be demonstrated at
least once every five years during the life of the well.
Item A: For each well class, enter the total number of wells (i.e.,
permitted and rule authorized) that have had a complete MIT this
federal fiscal year to date. Enter each well only once.
Item B: For each well class, enter the number of rule authorized
wells that have passed a complete MIT and the number that have
failed a complete MIT this federal fiscal year to date.

EPA Form 7520-3 (11-14) Revised

Item 1-4: For each well class, enter the number of times that wells
have received remedial action.

Paperwork Reduction Act
The public reporting and record keeping burden for this
collection of information is estimated to average 5 hours per
response. 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, 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 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. Environmental
Protection Agency (2822), 1200 Pennsylvania Ave., NW.,
Washington, DC 20460. Include the OMB control number in
any correspondence. Do not send the completed forms to this
address.

OMB No. 2040-0042

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

Approval expires 11/30/2014

UIC Federal Reporting System

I. Reporting Period

Part IV: Quarterly Exceptions List

From

(This information is collected under the authority of the Safe Drinking Water Act)
II.
Well

Name and Address

Date

Other (Specify)

Pipeline Severance

Well Shut-in

Criminal Referral

Civil Referral

Previous edition is obsolete.

Administrative Order

EPA Form 7520-4 (Rev. 12-11)

Typed or Printed Name and Title

Consent Agreement

Signature of Person Completing Form

Notice of Violation

Certification
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete.
punishable by fine or imprisonment or both under applicable law.

Enforcement

VII.

Mark ('X') Enforcement Type

Date of

Other (Specify)

Falsification

No.)

Violation

Formal Order

(Permit

Plugging and Abandonment

Type

Date of

ID No.

VI. Summary of Enforcement

Mark ('X') Violation Type

Injection Pressure

of Owner/Operator

Well

V. Summary of Violations

Well Mechanical Integrity

and

IV.

Unauthorized Injection

Class

III.

Compliance

I acknowledge that any knowingly false or misleading statement may be

Date

Telephone No.

Achieved

Instructions and Definitions
The Quarterly Exceptions list is used to track wells
reported in significant noncompliance (SNC) on EPA
Form 7520-2B for two or more consecutive quarters
without being addressed with a formal enforcement action
or being returned to compliance. Any SNC reported on
Form 7520-4 shall be reported until the well in SNC is
returned to compliance. The well is removed from the
exceptions list in the subsequent reporting period.
Section I - Reporting Period
All reporting is cumulative over the federal fiscal year, and
includes activities from October 1- March 31 (for midyear
reporting) and from October 1- September 30 (for end of
year reporting).
Section II - Well Class and Type
Enter the well class and type of each well in SNC for two
or more consecutive quarters. For Class I wells, specify IH
for hazardous waste, IM of municipal waste, Ii for
industrial waste. For Class II wells, specify IID for
saltwater disposal, IIR for enhanced recovery, IIH for
liquid hydrocarbon storage.
Section III - Name and Address of Owner/Operator
Enter the name and address of the primary contact for the
injection well. Use multiple lines of the form if needed.
(You may use one form for each owner/operator.)
Section IV - Well ID No. (Permit No.)
Enter the primacy agency-assigned I.D. number of the
injection well in SNC. If the well has a UIC permit
number, enter this as the I.D. number.
Section V - Summary of Violations
Enter the date the SNC violation was first identified and
place an “X” in the appropriate column. In the event that
there were multiple SNC violations for a single well, enter
each violation and the date it was identified on a separate
line.

Section VI - Summary of Enforcement
Enter the date an enforcement action was taken against the
SNC violation and place an “X” in the appropriate column.
In the event that there were multiple enforcement actions,
enter each enforcement action and the date it was taken on
a separate line.
Paperwork Reduction Act
The public reporting and record keeping burden for this
collection of information is estimated to average 2
hours per response. 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, 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
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. Environmental Protection Agency
(2822), 1200 Pennsylvania Ave., NW., Washington,
DC 20460. Include the OMB control number in any
correspondence. Do not send the completed forms to
this address.

EPA Form 7520-4 (11-14) Revised

OMB No. 2040-0042
United States Environmental Protection Agenc y

Approval Expires 11/30/2014

I. EPA ID Number

Underground Injection Control

T/A

Permit Application

(Collected under the authority of the Safe Drinking
Water Act. Sections 1421, 1422, 40 CFR 144)

Read Attached Instructions Before Starting

For Official Use Only
Application approved
mo

day

Date received

year

day

Permit Number

year

Well ID

II. Owner Name and Address

FINDS Number

III. Operator Name and Address

Owner Name

Street Address
City

State

IV. Commercial Facility

Phone Number

Street Address

ZIP CODE

City

V. Ownership

Phone Number
State

VI. Legal Contact

Yes

Private

Owner

Federal

Operator

ZIP CODE

VII. SIC Codes

Other
VIII. Well Status
Date Started

day

(Mark "x")

B. Modification/Conversion

year

C. Proposed

Operating
IX. Type of Permit Requested
A. Individual

(Mark "x" and specify if required)

Number of Existing Wells

B. Area

Number of Proposed Wells

X. Class and Type of Well
A. Class(es)

B. Type(s)

(enter code(s))

Name(s) of field(s) or project(s)

(see reverse)

C. If class is "other" or type is code 'x,' explain

D. Number of wells per type (if area permit)

XI. Location of Well(s) or Approximate Center of Field or Project
Latitude
Deg

Min

Longitude
Sec

XII. Indian Lands (Mark 'x')

Township and Range

Deg

Min

Sec

050

546

050

Sec

Twp

Range

1/4 Sec

Feet From

Line

Feet From

Line

Yes
No

XIII. Attachments
(Complete the following questions on a separate sheet(s) and number accordingly; see instructions)
For Classes I, II, III, (and other classes) complete and submit on a separate sheet(s) Attachments A--U (pp 2-6) as appropriate.
required. List attachments by letter which are applicable and are included with your application.

Attach maps where

XIV. 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 possibliity of fine and
imprisonment. (Ref. 40 CFR 144.32)
A. Name and Title

(Type or Print)

C. Signature

EPA Form 7520-6 (Rev. 12-11)

B. Phone No. (Area Code and No.)
D. Date Signed

Well Class and Type Codes
Class I

Wells used to inject waste below the deepest underground source of drinking
water.

Type “I”
“M”
“W”
“X”

Nonhazardous industrial disposal well
Nonhazardous municipal disposal well
Hazardous waste disposal well injecting below USDWs
Other Class I wells (not included in Type “I,” “M,” or “W”)

Class II

Oil and gas production and storage related injection wells.

Type “D”
“R”
“H”
“X”

Produced fluid disposal well
Enhanced recovery well
Hydrocarbon storage well (excluding natural gas)
Other Class II wells (not included in Type “D,” “R,” or “H”)

Class III

Special process injection wells.

Type “G”
“S”
“U”
“X”

Solution mining well
Sulfur mining well by Frasch process
Uranium mining well (excluding solution mining of conventional mines)
Other Class III wells (not included in Type “G,” “S,” or “U”)

Other Classes Wells not included in classes above.
Class V wells which may be permitted under §144.12.
Wells not currently classified as Class I, II, III, or V.

Attachments to Permit Application
Class

Attachments

I new well
existing

A, B, C, D, F, H – S, U
A, B, C, D, F, H – U

II new well
existing

A, B, C, E, G, H, M, Q, R; optional – I, J, K, O, P, U
A, E, G, H, M, Q, R, – U; optional – J, K, O, P, Q

III new well
existing

A, B, C, D, F, H, I, J, K, M – S, U
A, B, C, D, F, H, J, K, M – U

Other Classes

EPA Form 7520-6 (12-11)

To be specified by the permitting authority

page 2 of 6

INSTRUCTIONS - Underground Injection Control (UIC) Permit Application
Paperwork Reduction Act: The public reporting and record keeping burden for this collection of information is estimatedto average
224 hours for a Class I hazardous well application, 110 hours for a Class I non-hazardous well application,67 hours for a Class II well
application, and 132 hours for a Class III well application. 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, processing and maintaining information, and disclosing andproviding information; adjust the existing ways to comply with
any previously applicable instructions and requirements;train personnel to be able to respond to the collection of information; search
data sources; complete and review the collection of information; and, transmit or otherwise disclosethe information. An agency may
not conduct or sponsor, and a person is not required to respond to, a collectionof information unless it displays a currently valid OMB
control number. Send comments on the Agency’s need for this information, the accuracyof 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. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, DC 20460. Include the
OMB control number in any correspondence. Do not send the completed forms to this address.
This form must be completed by all owners or operators of Class I, II, and III injection wells and others who may be directed to
apply for permit by the Director.
I.

EPA I.D. NUMBER - Fill in your EPA Identification Number. If you do not have a number, leave blank.

II.

OWNER NAME AND ADDRESS - Name of well, well field or company and address.

III.

OPERATOR NAME AND ADDRESS - Name and address of operator of well or well field.

IV.

COMMERCIAL FACILITY - Mark the appropriate box to indicate the type of facility.

OWNERSHIP - Mark the appropriate box to indicate the type of ownership.

VI.

LEGAL CONTACT - Mark the appropriate box.

VII.

SIC CODES - List at least one and no more than four Standard Industrial Classification (SIC) Codes that best describe the
nature of the business in order of priority.

VIII.

WELL STATUS - Mark Box A if the well(s) were operating as injection wells on the effective date of the UIC Program for the
State. Mark Box B if wells(s) existed on the effective date of the UIC Program for the State but were not utilized for injection.
Box C should be marked if the application is for an underground injection project not constructed or not completed by the
effective date of the UIC Program for the State.

IX.

TYPE OF PERMIT - Mark “Individual” or “Area” to indicate the type of permit desired. Note that area permits are at the
discretion of the Director and that wells covered by an area permit must be at one site, under the control of one person and
do not inject hazardous waste. If an area permit is requested the number of wells to be included in the permit must be
specified and the wells described and identified by location. If the area has a commonly used name, such as the “Jay
Field,” submit the name in the space provided. In the case of a project or field which crosses State lines, it may be
possible to consider an area permit if EPA has jurisdiction in both States. Each such case will be considered individually, if
the owner/operator elects to seek an area permit.

CLASS AND TYPE OF WELL - Enter in these two positions the Class and type of injection well for which a permit is
requested. Use the most pertinent code selected from the list on the reverse side of the application. When selecting type X
please explain in the space provided.

XI.

LOCATION OF WELL - Enter the latitude and longitude of the existing or proposed well expressed in degrees, minutes, and
seconds or the location by township, and range, and section, as required by 40 CFR Part 146. If an area permit is being
requested, give the latitude and longitude of the approximate center of the area.

XII.

INDIAN LANDS - Place an “X” in the box if any part of the facility is located on Indian lands.

XIII.

ATTACHMENTS - Note that information requirements vary depending on the injection well class and status. Attachments
for Class I, II, III are described on pages 4 and 5 of this document and listed by Class on page 2. Place EPA ID number in
the upper right hand corner of each page of the Attachments.

CERTIFICATION - All permit applications (except Class II) must be signed by a responsible corporate officer for a
corporation, by a general partner for a partnership, by the proprietor of a sole proprietorship, and by a principal executive or
ranking elected official for a public agency. For Class II, the person described above should sign, or a representative duly
authorized in writing.
EPA Form 7520-6
Page 3 of 6
XIV.

INSTRUCTIONS - Attachments
Attachments to be submitted with permit application for Class I, II, III and other wells.
A.

AREA OF REVIEW METHODS - Give the methods and, if appropriate, the calculations used to determine the size of
the area of review (fixed radius or equation).The area of review shall be a fixed radius of 1/4 mile from the well bore
unless the use of an equation is approved in advance by the Director.

MAPS OF WELL/AREA AND AREA OF REVIEW - Submit a topographic map, extending one mile beyond the property
boundaries, showing the injection well(s) or project area for which a permit is sought and the applicable area of
review. The map must show all intake and discharge structures and all hazardous waste treatment, storage, or
disposal facilities. If the application is for an area permit, the map should show the distribution manifold (if applicable)
applying injection fluid to all wells in the area, including all system monitoring points. Within the area of review, the
map must show the following:
Class I
The number, or name, and location of all producing wells, injection wells, abandoned wells, dryholes, surface bodies
of water, springs, mines (surface and subsurface), quarries, and other pertinent surface features, including
residences and roads, and faults, if known or suspected. In addition, the map must identify those wells, springs, other
surface water bodies, and drinking water wells located within one quarter mile of the facility property boundary. Only
information of public record is required to be included in this map;
Class II
In addition to requirements for Class I, include pertinent information known to the applicant. This requirement
does not apply to existing Class II wells;
Class III
In addition to requirements for Class I, include public water systems and pertinent information known to the
applicant.

CORRECTIVE ACTION PLAN AND WELL DATA - Submit a tabulation of data reasonably available from public records
or otherwise known to the applicant on all wells within the area of review, including those on the map required in B,
which penetrate the proposed injection zone. Such data shall include the following:
Class I
Adescription of each well's types,construction, date drilled, location, depth, record of plugging and/or completion, and
any additional information the Director may require. In the case of new injection wells, include thecorrective action
proposed to be taken by the applicant under 40 CFR 144.55.
Class II
In addition to requirement for Class I, in the case of Class II wellsoperating over the fracture pressure of the injection
formation, all known wells within the area of review which penetrate formations affected by the increase in pressure.
This requirement does not apply to existing Class II wells.
Class III
In addition to requirements for Class I, the corrective action proposed under 40 CFR 144.55 for all Class III wells.

MAPS AND CROSS SECTION OF USDWs - Submit maps and cross sections indicating the vertical limits of all
underground sources of drinking water within the area of review (both vertical and lateral limits for Class I), their
position relative to the injection formation and the direction of water movement, where known, in every underground
source of drinking water which may be affected by the proposed injection. (Does not apply to Class II wells.)

EPA Form 7520-6

Page 4 of 6

NAME AND DEPTH OF USDWs (CLASS II) - For Class II wells, submit geologic name, and depth to bottom of all
underground sources of drinking water which may be affected by the injection.

MAPS AND CROSS SECTIONS OFGEOLOGIC STRUCTURE OF AREA - Submit maps and cross sections detailingthe
geologic structure of the local area (including the lithology of injection and confining intervals) andgeneralized maps
and cross sections illustrating the regional geologic setting. (Does not apply to Class II wells.)

GEOLOGICAL DATA ON INJECTION AND CONFINING ZONES (Class II) - For Class II wells, submit appropriate
geological data on theinjection zone and confining zones including lithologic description, geological name, thickness,
depth and fracture pressure.

OPERATING DATA - Submit the following proposed operating data foreach well (including all those to be covered by
area permits): (1) average and maximum daily rate and volume of the fluids to be injected; (2) average and maximum
injection pressure; (3) nature of annulus fluid; (4) for Class I wells, source and analysis ofthe chemical, physical,
radiological and biological characteristics, including density and corrosiveness, of injection fluids; (5) for Class II
wells, source and analysis of the physical andchemical characteristics of the injection fluid; (6) for Class III wells, a
qualitative analysis and ranges in concentrations of all constituents of injected fluids. If the information is proprietary,
maximum concentrations only may be submitted, but all records must be retained.

FORMATION TESTING PROGRAM - Describe the proposed formation testing program.For Class I wells the program
must be designed to obtain data on fluid pressure, temperature, fracture pressure, other physical, chemical, and
radiological characteristics of the injection matrix and physical and chemical characteristics of the formation fluids.
For Class II wells the testing program must be designed to obtain data on fluid pressure, estimated fracture
pressure, physical and chemical characteristics of the injection zone. (Does not apply to existing Class II wells or
projects.)
For Class III wells the testing must bedesigned to obtain data on fluid pressure, fracture pressure, and physical and
chemical characteristics of the formation fluids if the formation is naturally water bearing. Only fracture pressure is
required if the program formation is not water bearing. (Does not apply to existing Class III wells or projects.)

STIMULATION PROGRAM - Outline any proposed stimulation program.

INJECTION PROCEDURES - Describe the proposed injection procedures including pump, surge, tank, etc.

CONSTRUCTION PROCEDURES - Discuss the construction procedures (according to §146.12 for Class I, §146.22 for
Class II, and §146.32 for Class III) to be utilized. This should include details of the casing and cementing program,
logging procedures, deviation checks, and the drilling, testing and coring program, and proposed annulus fluid.
(Request and submission of justifying data must be made to use an alternative to packer for Class I.)

CONSTRUCTION DETAILS - Submit schematic or other appropriate drawings of the surface and subsurface
construction details of the well.

CHANGES IN INJECTED FLUID - Discuss expected changes in pressure, native fluid displacement, and direction of
movement of injection fluid. (Class III wells only.)

PLANS FOR WELL FAILURES - Outline contingency plans (proposed plans, if any, for Class II) to cope with all
shut-ins or wells failures, so as to prevent migration of fluids into any USDW.

MONITORING PROGRAM - Discuss the planned monitoring program. This should be thorough, including maps
showing the number and location of monitoring wells as appropriate and discussion of monitoring devices, sampling
frequency, and parameters measured. If a manifold monitoring program is utilized, pursuant to §146.23(b)(5),
describe the program and compare it to individual well monitoring.

PLUGGING AND ABANDONMENT PLAN - Submit a plan for plugging and abandonment of the well including: (1)
describe the type, number, and placement (including the elevation of the top and bottom) of plugs to be used; (2)
describe the type, grade, and quantity of cement to be used; and (3) describe the method to be
used to place plugs,
including the method used to place the wellin a state of static equilibrium prior to placement of the plugs. Also for a
Class III well that underlies or is in an exempted aquifer, demonstrate adequate protection ofUSDWs. Submit this
information on EPA Form 7520-14, Plugging and Abandonment Plan.

EPA Form 7520-6

Page 5 of 6

NECESSARY RESOURCES - Submit evidence such as a surety bond or financial statement to verify that the
resources necessary to close, plug or abandon the well are available.

AQUIFER EXEMPTIONS - If an aquifer exemption is requested, submit data necessary to demonstrate that theaquifer
meets the following criteria:(1) does not serve as a source of drinking water; (2) cannot now and will not in the future
serve as a source of drinking water; and (3) the TDS content of the ground water is morethan 3,000 and less than
10,000 mg/l and is not reasonablyexpected to supply a public water system. Data to demonstrate that the aquifer is
expected to be mineral or hydrocarbon production, such as general description of themining zone, analysis of the
amenability of the mining zone to the proposed method, and time table for proposed development must also be
included. For additional information on aquifer exemptions, see 40 CFR Sections 144.7 and 146.04.

EXISTING EPA PERMITS - List program and permit number of any existing EPA permits, for example, NPDES,
PSD, RCRA, etc.

DESCRIPTION OF BUSINESS - Give a brief description of the nature of the business.

EPA Form 7520-6

Page 6 of 6

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency
Washington, DC 20460

Application To Transfer Permit
Name and Address of Existing Permittee

Name and Address of Surface Owner

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

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.
W

Well Activity
____ Class I

Well Status
____ Operating

____ Class II
____ Brine Disposal
____ Enhanced Recovery

____ Modification/Conversion
____ Proposed

Type of Permit
____ Individual
____ Area
Number of Wells ____

____ Hydrocarbon Storage
S

____ Class III
____ Other
Lease Number

Well Number
Name and Address of New Operator

Name(s) and Address(es) of New Owner(s)

Attach to this application a written agreement between the existing and new permittee containing a
specific date for transfer of permit responsibility, coverage, and liability between them.
The new permittee must show evidence of financial responsibility by the submission of a surety bond, or
other adequate assurance, such as financial statements or other materials acceptable to the Director.

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 7520-7 (Rev. 12-11)

Signature

Date Signed

PAPERWORK REDUCTION ACT

The public reporting and record keeping burden for this collection of information is estimated to average 5 hours per response.
Burden means the total time, effort, or financial resource expendedby persons to generate, maintain, retain, or disclose or
provide information to or for a FederalAgency. 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 the collection ofinformation; 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 co l l e c t i o n
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 thecompleted forms to
this address.

Well Class and Type Code
Class I

Wells used to inject waste below the deepest underground source of drinking water.

Type “I”
“M”
“W”
“X”

Nonhazardous industrial disposal well
Nonhazardous municipal disposal well
Hazardous waste disposal well injecting below USDWs
Other Class I wells (not included in Type “I,” “M,” or “W”)

Class II

Oil and gas production and storage related injection wells.

Type “D”
“R”
“H”
“X”

Produced fluid disposal well
Enhanced recovery well
Hydrocarbon storage well (excluding natural gas)
Other Class II wells (not included in Type “D,” “R,” or “H”)

Class III

Special process injection wells.

Type “G”
“S”
“U”
“X”

Solution mining well
Sulfur mining well by Frasch process
Uranium mining well
Other Class III wells (not included in Type “G,” “S,” or “U”)

Other Classes Wells not included in classes above.
Class V wells which may be permitted under § 144.12
Wells not currently classified as Class I, II, III, or V

EPA Form 7520-7 (12-11) Reverse

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency
Washington, DC 20460

Injection Well Monitoring Report
Year

Month

Injection Pressure (PSI)
1. Minimum
2. Average
3. Maximum
Injection Rate (Gal/Min)
1. Minimum
2. Average
3. Maximum
Annular Pressure (PSI)
1. Minimum
2. Average
3. Maximum
Injection Volume (Gal)
1. Monthly Total
2. Yearly Cumulative
Temperature (F °)
1. Minimum
2. Average
3. Maximum
pH
1. Minimum
2. Average
3. Maximum
Other

Name and Address of Permittee

Name and Official Title (Please type or print)

EPA Form 7520-8 (Rev. 12-11)

Permit Number

Signature

Date Signed

Paperwork Reduction Act
The public reporting and record keeping burden for this collection of information is estimated to average 25
hours per quarter for operators of Class I hazardous wells, 16 hours per quarter for operators of Class I nonhazardous wells, and 30 hours per quarter for operators of Class III wells.
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, 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 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.
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.

EPA Form 7520-8 Reverse

OMB No. 2040-0042

Approval Expires 11/30/2014

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 ____

Well Status

Type of Permit

____ Class I

____ Operating

____ Individual

____ Class II
____ Brine Disposal
____ Enhanced Recovery

____ Modification/Conversion

____ Area : Number of Wells ____

____ Proposed

____ Hydrocarbon Storage
____ Class III
____ Other
Lease Number _______________

Well Number _______________

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

EPA Form 7520-9 (Rev. 12-11)

Signature

Date Signed

PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is estimated to average 49 hours per response for a Class I
hazardous facility, and 47 hours per response for a Class I non-hazardous facility. 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, 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 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. 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.

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.

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

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

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency
Washington, DC 20460

COMPLETION REPORT FOR BRINE DISPOSAL,
HYDROCARBON STORAGE, OR ENHANCED RECOVERY
Name and Address of Existing Permittee

Name and Address of Surface Owner

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

Section ____ Township ____ Range ____

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

WELL ACTIVITY

TYPE OF PERMIT

Brine Disposal

Individual

Enhanced Recovery

Area

Hydrocarbon Storage

Injection Interval

Average

Feet

Maximum

Average

Brackish Water

Liquid Hydrocarbon
Date Drilling Began

Lease Name

Fresh Water
Other

Date Well Completed

to Feet

Depth to Bottom of Lowermost Freshwater
Formation (Feet)

Maximum

Type of Injection Fluid (Check the appropriate block(s))

Well Number

Name of Injection Zone
Permeability of Injection Zone

Date Drilling Completed

Porosity of Injection Zone
CEMENT

CASING AND TUBING
OD Size

Number of Wells ____

Anticipated Daily Injection Volume (Bbls)

Anticipated Daily Injection Pressure (PSI)

Salt Water

Estimated Fracture Pressure
of Injection Zone

Wt/Ft - Grade - New or Used

Depth

Sacks

INJECTION ZONE STIMULATION
Interval Treated

HOLE
Class

Depth

Bit Diameter

WIRE LINE LOGS, LIST EACH TYPE

Materials and Amount Used

Log Types

Logged Intervals

Complete Attachments A -- E listed on the reverse.

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
possibliity of fine and imprisonment. (Ref. 40 CFR 144.32)
Name and Official Title (Please type or print)

EPA Form 7520-10 (Rev. 12-11)

Signature

Date Signed

ATTACHMENTS

Present a schematic or other appropriate drawing of the surface and subsurface
construction details of the well as built.

Describe the method and results of mechanical integrity testing.

Present the results of that portion of those logs, test, and cores which specifically
relate to (1) underground sources of drinking water and the confining zone(s) and
(2) the injection and adjacent formations.

Present the status of corrective action on defective wells in the area of review.

Provide to EPA, with the completion report, one final print of all geophysical logs
run.
PAPERWORK REDUCTION ACT

The public reporting and record keeping burden for this collection of information is estimated to average 4 hours
per well. 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, 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 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. 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.

EPA Form 7520-10 Reverse

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency
Washington, DC 20460

ANNUAL DISPOSAL/INJECTION WELL MONITORING REPORT
Name and Address of Existing Permittee

Name and Address of Surface Owner

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

Section ____ Township ____ Range ____

WELL ACTIVITY
Brine Disposal
Enhanced Recovery
Hydrocarbon Storage

TYPE OF PERMIT
Individual
Area
Number of Wells ____

Lease Name

Well Number

INJECTION PRESSURE
MONTH

YEAR

AVERAGE PSIG

TOTAL VOLUME INJECTED

MAXIMUM PSIG

BBL

MCF

TUBING -- CASING ANNULUS PRESSURE
(OPTIONAL MONITORING)
MINIMUM PSIG

MAXIMUM PSIG

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
possibliity of fine and imprisonment. (Ref. 40 CFR 144.32)
Name and Official Title (Please type or print)

EPA Form 7520-11 (Rev. 12-11)

Signature

Date Signed

PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is estimated to average 30 hours per quarter.
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, 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 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. 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.

EPA Form 7520-11 Reverse

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency
Washington, DC 20460

WELL REWORK RECORD
Name and Address of Permittee

Name and Address of Contractor

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

Section ____ Township ____ Range ____

WELL ACTIVITY

Total Depth Before Rework

Brine Disposal
Enhanced Recovery
Hydrocarbon Storage

Total Depth After Rework
Date Rework Commenced

Lease Name
Date Rework Completed

TYPE OF PERMIT
Individual
Area
Number of Wells ____
Well Number

WELL CASING RECORD -- BEFORE REWORK
Casing
Size

Cement
Depth

Sacks

Perforations
Type

From

WELL CASING RECORD -- AFTER REWORK
Casing
Size

Cement
Depth

Sacks

Acid or Fracture
Treatment Record

(Indicate Additions and Changes Only)

Perforations
Type

From

Acid or Fracture
Treatment Record

WIRE LINE LOGS, LIST EACH TYPE

DESCRIBE REWORK OPERATIONS IN DETAIL
USE ADDITIONAL SHEETS IF NECESSARY

Log Types

Logged Intervals

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
possibliity of fine and imprisonment. (Ref. 40 CFR 144.32)
Name and Official Title (Please type or print)

EPA Form 7520-12 (Rev. 12-11)

Signature

Date Signed

PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is estimated to average 4 hours per
response annually. 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, 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 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. 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.

EPA Form 7520-12 Reverse

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency
Washington, DC 20460

PLUGGING AND ABANDONMENT PLAN
Name and Address of Facility

Name and Address of Owner/Operator

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

Section ____ Township ____ Range ____

TYPE OF AUTHORIZATION

WELL ACTIVITY

Individual Permit

CLASS I

Area Permit

CLASS II
Brine Disposal

Rule

Enhanced Recovery

Number of Wells ____

Hydrocarbon Storage
CLASS III

Lease Name

Well Number

CASING AND TUBING RECORD AFTER PLUGGING
SIZE

WT (LB/FT)

TO BE PUT IN WELL (FT)

METHOD OF EMPLACEMENT OF CEMENT PLUGS

TO BE LEFT IN WELL (FT)

HOLE SIZE

The Balance Method
The Dump Bailer Method
The Two-Plug Method
Other

CEMENTING TO PLUG AND ABANDON DATA:

PLUG #1

PLUG #2

PLUG #3

PLUG #4

PLUG #5

PLUG #6

Size of Hole or Pipe in which Plug Will Be Placed (inches)
Depth to Bottom of Tubing or Drill Pipe (ft.)
Sacks of Cement To Be Used (each plug)
Slurry Volume To Be Pumped (cu. ft.)
Calculated Top of Plug (ft.)
Measured Top of Plug (if tagged ft.)
Slurry Wt. (Lb./Gal.)
Type Cement or Other Material (Class III)
LIST ALL OPEN HOLE AND/OR PERFORATED INTERVALS AND INTERVALS WHERE CASING WILL BE VARIED (if any)
From

From

Estimated Cost to Plug Wells

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
possibliity of fine and imprisonment. (Ref. 40 CFR 144.32)
Name and Official Title (Please type or print)

EPA Form 7520-14 (Rev. 12-11)

Signature

Date Signed

PLUG #7

Paperwork Reduction Act Notice
The public reporting and record keeping burden for this collection of information is
estimated to average 4.5 hours for operators of Class I hazardous wells, 1.5 hours for
operators of Class I non-hazardous wells, 3 hours for operators of Class II wells,
and 1.5 hours for operators of Class III wells.
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; adjust the
existing ways to comply with any previously applicable instructions and requirements;
train personnel 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. The OMB control numbers for EPA’s regulations are listed in
40 CFR Part 9 and 48 CFR Chapter 15.
Please 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, Office of
Environmental Information, Collection Strategies Division, U.S. Environmental
Protection Agency (2822), Ariel Rios Building, 1200 Pennsylvania Ave., NW.,
Washington, DC 20460; and to the Office of Information and Regulatory Affairs, Office
of Management and Budget, 725 17th Street, NW., Washington, DC 20503, Attention:
Desk Officer for EPA. Please include the EPA ICR number and OMB control number
in any correspondence.

EPA Form 7520-14 Reverse

Type or print all information. See reverse for instructions.

OMB No. 2040-0042

INVENTORY OF INJECTION WELLS

1. DATE PREPARED

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
OFFICE OF GROUND WATER AND DRINKING WATER

(Year, Month, Day)

Approval Expires 11/30/2014

2. FACILITY ID NUMBER

(This information is collected under the authority of the Safe Drinking Water Act)

PAPERWORK REDUCTION ACT NOTICE

The public reporting burden for this collection of information is estimated at about 0.5 hour per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding the burden estimate or any other aspect of this collection of information, includingsuggestions
for reducing this burden, Director, Collection Strategies Division (2822), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue,
NW, Washington, DC 20460, and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC20503.

3. TRANSACTION TYPE

(Please mark one of the following)

Deletion

First Time Entry

Entry Change

Replacement

4. FACILITY NAME AND LOCATION
A. NAME (last, first, and middle initial)

C. LATITUDE

DEG

MIN

E. TOWNSHIP/RANGE

SEC

.
B. STREET ADDRESS/ROUTE NUMBER

D. LONGITUDE

DEG

050
F. CITY/TOWN

G. STATE

MIN

TOWNSHIP

RANGE

SECT

1/4 SECT

SEC

546

H. ZIP CODE

I. NUMERIC
COUNTY CODE

J. INDIAN LAND
(mark "x")

Yes

5. LEGAL CONTACT:
A. TYPE (mark "x")
Owner

B. NAME (last, first, and middle initial)

C. PHONE
(area code
and number)

Operator

D. ORGANIZATION

E. STREET/P.O. BOX

F. CITY/TOWN

G. STATE

I. OWNERSHIP (mark "x")

H. ZIP CODE

PRIVATE

PUBLIC

STATE

FEDERAL

SPECIFY OTHER

6. WELL INFORMATION:
A. CLASS
AND
TYPE

B. NUMBER OF WELLS
COMM

NON-COMM

C. TOTAL
NUMBER
OF WELLS

D. WELL OPERATION STATUS
UC

COMMENTS (Optional):
AN

0
0
0
KEY:

DEG = Degree
MIN = Minute
SEC = Second

0
0

0
EPA Form 7520-16 (Rev. 12-11)

SECT = Section
1/4 SECT = Quarter Section

COMM = Commercial
NON-COMM = Non-Commercial
AC = Active
UC = Under Construction
TA = Temporarily Abandoned
PA = Permanently Abandoned and Approved by State
AN = Permanently Abandoned and not Approved by State

INSTRUCTIONS AND DEFINITIONS
SECTION 1. DATE PREPARED: Enter date in order of year, month,
and day.

SECTION 4. FACILITY NAME & LOCATION (CONT’D.):
I.

SECTION 2. FACILITY ID NUMBER: In the first two spaces, insert
the appropriate U.S. Postal Service State Code. In the third space, insert
one of the following one letter alphabetic identifiers:
D - DUNS Number,
G - GSA Number, or
S - State Facility Number.
In the remaining spaces, insert the appropriate nine digit DUNS, GSA, or
State Facility Number. For example, A Federal facility (GSA 123456789) located in Virginia would be entered as : VAG123456789.

SECTION 5. LEGAL CONTACT:
A.

SECTION 3. TRANSACTION TYPE: Place an “x” in the applicable

box. See below for further instructions.
Deletion. Fill in the Facility ID Number.
First Time Entry. Fill in all the appropriate information.
Entry Change.
Fill in the Facility ID Number and the information
that has changed.
Replacement.

C.
D.

SECTION 4. FACILITY NAME AND LOCATION:
A.
B.
C.
D.
E.

F.
G.
H.

Name. Fill in the facility’s official or legal name.
Street Address. Self Explanatory.
Latitude. Enter the facility’s latitude (all latitudes assume
North Except for American Samoa).
Longitude. Enter the facility’s longitude (all longitudes assume
West except Guam).
Township/Range. Fill in the complete township and range.
The first 3 spaces are numerical and the fourth is a letter
(N,S,E,W) specifying a compass direction. A township is North
or South of the baseline, and a range is East or West of the
principal meridian (e.g., 132N, 343W).
City/Town. Self Explanatory.
State. Insert the U.S. Postal Service State abbreviation.
Zip Code. Insert the five digit zip code plus any extension.

Numeric County Code. Insert the numeric county code from
the Federal Information Processing Standards Publication (FIPS
Pub 6-1) June 15, 1970, U.S. Department of Commerce,
National Bureau of Standards. For Alaska, use the Census Division
Code developed by the U.S. Census Bureau.
Indian Land. Mark an “x” in the appropriate box (Yes or No)
to indicate if the facility is located on Indian land.

E.
F.
G.
H.
I.

Type. Mark an “x” in the appropriate box to indicate the type
of legal contact (Owner or Operator). For wells operated by lease,
the operator is the legal contact.
Name. Self Explanatory.
Phone. Self Explanatory.
Organization. If the legal contact is an individual, give the
name of the business organization to expedite mail distribution.
Street/P.O. Box. Self Explanatory.
City/Town. Self Explanatory.
State. Insert the U.S. Postal Service State abbreviation.
Zip Code. Insert the five digit zip code plus any extension.
Ownership. Place an “x” in the appropriate box to indicate
ownership status.

SECTION 6. WELL INFORMATION:
A.

C.
D.

Class and Type. Fill in the Class and Type of injection wells
located at the listed facility. Use the most pertinent code
(specified below) to accurately describe each type of injection
well. For example, 2R for a Class II Enhanced Recovery Well, or
3M for a Class III Solution Mining Well, etc.
Number of Commercial and Non-Commercial Wells.
Enter the total number of commercial and non-commercial wells
for each Class/Type, as applicable.
Total Number of Wells. Enter the total number of injection
wells for each specified Class/Type.
Well Operation Status. Enter the number of wells for each
Class/Type under each operation status (see key on other side).

INJECTION WELL CLASS AND TYPE CODES
CLASS I Industrial, Municipal, and Radioactive Waste Disposal Wells
used to inject waste below the lowermost Underground Source of Drinking
Water (USDW).
TYPE

1I
1M

Non-Hazardous Industrial Disposal Well.
Non-Hazardous Municipal Disposal Well.

Hazardous Waste Disposal Well injecting below the
lowermost USDW.
Radioactive Waste Disposal Well.
Other Class I Wells.

1R
1X

CLASS III (CONT’D.)
TYPE

3S
3T
3U
3X

Sulfur Mining Well by Frasch Process.
Geothermal Well.
Uranium Mining Well.
Other Class III Wells.

CLASS IV Wells that inject hazardous waste into/above USDWs.
TYPE

4H
4R

Hazardous Facility Injection Well.
Remediation Well at RCRA or CERCLA site.

CLASS II Oil and Gas Production and Storage Related Injection Wells.
CLASS V Any Underground Injection Well not included in Classes I
TYPE

2A
2D
2H
2R
2X

Annular Disposal Well.
Produced Fluid Disposal Well.
Hydrocarbon Storage Well.
Enhanced Recovery Well.
Other Class II Wells.

CLASS III Special Process Injection Wells.
TYPE

3G
3M

In Situ Gasification Well
Solution Mining Well.

EPA Form 7520-16 (Revised 12-11)

through IV.
TYPE

5A
5B
5C
5D
5E
5F
5G
5H
5I
5J

Industrial Well.
Beneficial Use Well.
Fluid Return Well.
Sewage Treatment Effluent Well.
Cesspools (non-domestic).
Septic Systems.
Experimental Technology Well.
Drainage Well.
Mine Backfill Well.
Waste Discharge Well.

PAPERWORK REDUCTION ACT The public reporting and record keeping burden for this collection of information is

estimated to average 0.5 hours per response. 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, 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 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. 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.

EPA Form 7520-16 (Revised 12-11)

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
Approval expires 11/30/2014

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.

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.

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.

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.

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.

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

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.

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).

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

File Type	application/pdf
File Title	EPA Form 7520-5 (Rev. 8-01) Part V Summary of UIC Grant Utilization
Subject	EPA Form 7520-5 (Rev. 8-01) Part V Summary of UIC Grant Utilization - OMB No. 2040-0042
Author	United States Environmental Protection Agency
File Modified	2014-12-16
File Created	2014-10-10