Appendix D

Appendix D:
UIC Reporting Forms

APPENDIX D
Underground Injection Control Program Reporting Forms
Number
7520-1
7520-2A
7520-2B
7520-3
7520-4
7520-6
7520-7
7520-8
7520-11
7520-12
7520-14
7520-16
7520-17
7520-18
7520-19

Form
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
Annual Disposal/Injection Well Monitoring Report
Well Rework Record
Plugging and Abandonment Plan
Inventory of Injection Wells
Pre-Closure Notification Form
Completion Report for Injection Wells
Well Rework, Plugging & Abandonment Plan, or Plugging & Abandonment Affidavit

Please type or print all information. Please read instructions.

OMB No. 2040-0042 Form Expires 12/31/18

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

I. Name and Address of Reporting 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

D

Modification
Issued

E

HC

2D

2R

2H

III

IV

V

A

Wells
Identified
for C/A

B

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Number of Permits Denied/Withdrawn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

ER

Number of Permit Applications Received

A

VI.
Permit
Determination

I

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

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. 12-31-15)

Previous edition is obsolete.

Date

Telephone No.

Instructions and Definitions
All reporting is cumulative over the fiscal year, and includes
activities from October 1 – September 30. All fields should contain
a value. Do not leave blank fields. Enter 0 if there are no wells
affected or no activities that occurred pertaining to the information
requested. Enter NA if the field or section is not applicable to the
submitter (e.g., the well type is not overseen by the submitter).
Enter U if the information is unknown or not captured; fields
designated as U require explanation.

Wells Deficient: For rule authorized Class II wells, enter the
number of reviewed wells that were found deficient (not in
compliance with UIC regulations) and that received corrective
action.

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, including incomplete applications, for individual and
area permits. Include all applications regardless of whether they
are for “New Wells” or “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.

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.

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.

A “New Well Field” has only “New Wells” or a combination of
“New Wells” and “Existing Wells.” An “Existing Well Field”
contains only “Existing Wells.”

“Other” includes any producing well, operable injection well, dry
hole, exploratory well, etc., that penetrates the injection zone in the
AoR.

Section VI. Permit Determination
Permit Determinations include the approval, withdrawal, 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.
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 a 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. These Class II
wells should be routinely reviewed at least once every five years
during the life of the well.

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 (12-31-15) 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 12/31/2018

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)
III. State Contact (name, telephone no.)

II. Date Prepared (month, day, year)

IV. Reporting Period (month, year)
From

To

October 1, 20

Class and Type of Injection Wells
II
Item
Total
Wells

A

HC

2D

2R

2H

III

IV

V

Number of Unauthorized
Injection Violations

2. Number of Mechanical Integrity Violations

Summary
of

ER

Number of Wells with Violations
1.

V.

I

SWD

Total
Violations

B

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

A

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

B

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 (12-31-15)

Replaces EPA Form 7520-2 which is obsolete

Date

Telephone No.

Definitions and Instructions

All reporting is cumulative over the fiscal year, and includes activities
from October 1 – September 30. All fields should contain a value. Do
not leave blank fields. Enter 0 if there are no wells affected or no
activities that occurred pertaining to the information requested. Enter
NA if the field or section is not applicable to the submitter (e.g., the
well type is not overseen by the submitter). Enter U if the information
is unknown or not captured; fields designated as U require explanation.
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
one or more violations that have been addressed by the specific type of
enforcement action 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
one or more violations have been addressed by the specific type of
enforcement action indicated in the row, in this federal fiscal year to
date. (Count each draft and final Administrative Order.)
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 through the second quarter for midyear reporting and
through the fourth quarter for end of the year reporting.
B. For each well class, enter the number of wells returned to
compliance through the second quarter for midyear reporting and
through the fourth quarter for end of the end of year reporting.
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 a
one year period prior to 90 days before the end of the fiscal year
reporting cycle i.e., 6/30.
• 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 (11-15-31) 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 12/31/18

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

A

Number of Wells with SNC Violations

B

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)

A

Number of Wells with
Enforcement Actions Against SNC

V.
Summary
of
Significant

Total

Non-

Violations

Compliance
(SNC)

Total
Wells

2R

2H

III

IV

V

3. Number of Administrative Orders
Total
Enforcement

B

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

HC

2D

2. Number of Consent Agreements/Orders

Summary

Enforcement

ER

1. Number of Notices of Violation

VI.

of

I

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

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 For m

EPA Form 7520-2B (Rev. 12-1-15)

Replaces EPA Form 7520 -2 which is obsolete.

Date

Telephone No.

Instructions and Definitions
All reporting is cumulative over the fiscal year, and includes activities from
October 1 – September 30. All fields should contain a value. Do not leave
blank fields. Enter 0 if there are no wells affected or no activities that
occurred pertaining to the information requested. Enter NA if the field or
section is not applicable to the submitter (e.g., the well type is not overseen
by the submitter). Enter U if the information is unknown or not captured;
fields designated as U require explanation.
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:
•
Contamination of a USDW;
•
Injection of unauthorized fluid(s);
•
Injection into unauthorized zones;
•
Failure to cease injection after loss of MI detected; Failure to
comply with corrective action requirements;
•
Failure to operate automatic shutdown system;
•
Failure to operate automatic warning system;
•
Unauthorized plugging and abandonment;
•
Violation of a Formal Order;
•
Knowing submission of false information;
•
Violations involving loss of mechanical integrity;
•
Violations of maximum injection pressure;
•
Failure to install and/or operate injection pressure and annulus
pressure monitoring systems or other monitoring systems, required
by permit or rule; and
•
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. List
these Class I specific violations under Other SNC Violations unless they
clearly fall within the categories of violations in the list below.
2. The following violations for a Class II, III, or V well:
•
Unauthorized Injection – Any unauthorized emplacement of fluids
(where formal authorization is required);
•
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;
•
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;
•
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;
•
Violation of a Formal Order – Any violation of a formal
enforcement action, including an administrative or judicial order,
consent agreement, judgment, or equivalent action;
•
Falsification – The knowing submission or use of any false
information in a permit application, periodic report or special
request for information about a well; or
•
Other SNC Violations.
3. Any violation for a Class IV well.

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 8, enter the number of times
wells with SNC violations have received each type of 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.

EPA Form 7520-2B (12-31-15) 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 12/31/18

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

A

V.
Summary
of

Total
Inspections

B

Inspections

Total
Wells

A
B

For
Significant

of

C

Leak

Mechanical
Integrity
(MI)

For
Fluid

D

Migration

Total
Wells

A

VII.
Summary
of
Remedial
Action

ER

HC

2D

2R

2H

III

IV

V

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

I

SWD

Total
Remedial

B

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

Well Failed

Well Failed

Well Failed

Well Failed

Well Failed

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)

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 7520-3 (Rev. 12-31-15)

Previous edition is obsolete.

Date

Telephone No.

Instructions and Definitions
All reporting is cumulative over the fiscal year, and includes
activities from October 1 – September 30. All fields should
contain a value. Do not leave blank fields. Enter 0 if there are no
wells affected or no activities that occurred pertaining to the
information requested. Enter NA if the field or section is not
applicable to the submitter (e.g., the well type is not overseen by
the submitter). Enter U if the information is unknown or not
captured; fields designated as U require explanation.
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.

Item C: Significant Leak Tests: (this federal fiscal 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):
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 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.

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.)

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 (12-31-15) 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 12/31/18

UIC Federal Reporting System

I. Reporting Period

Part IV: Quarterly Exceptions List

From

To

(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. 12-31-15)

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 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.
Section VII – Date Compliance Achieved

Do not leave the form blank. If there are no exceptions,
indicate none.
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.

Enter the date compliance is achieved for each violation.
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 (12-31-15) Revised

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

Approval Expires 11/30/2014

For Official Use Only
Date Received

Underground Injection Control

Permit Application for a Class I Well
(Collected under the authority of the Safe Drinking Water Act.
Sections 1421, 1422, and 40 CFR Part 144)

Permit Number

Read Attached Instructions Before Starting
I. Owner Name, Address, Phone Number and/or Email

III. Commercial Facility

IV. Ownership

II. Operator Name, Address, Phone Number and/or Email

V. Permit Action Requested

VI. SIC Code(s)

VII. Indian Country

Yes

Private

New Permit

Yes

No

Federal

Permit Renewal

No

State/Tribal/
Municipal

Modification
Add Well to Area Permit
Other

VIII. Type of Permit (For multiple wells, use additional page(s) to provide the information requested for each additional well)
A. Individual

Number of Wells

Well Field and/or Project Names

B. Area
IX. Class and Type of Well (see reverse)
A. Class

B. Type (enter code(s))

C. If type code is "X," explain.

X. Well Status

XI. Well Information

A. Operating
Date Injection Started

B. Conversion
Date Well Constructed

API Number

C. Proposed

Permit (or EPA ID) Number
Full Well Name

XII. Location of Well or, for Multiple Wells, Approximate Center of Field or Project
Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location
1/4 of

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Range

Latitude
Longitude

XIII. Attachments

In addition to this form, complete Attachments A-U (as appropriate for the specific well
class) on separate sheets. Submit complete information, as required in the instructions and
list all attachments, maps or other figures, by the applicable letter.
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)
Name and Official Title

(Please Type or Print)

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

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520-6 (CLASS I WELLS)
A permit application must be completed by all owners or operators of current or proposed Class I, II, and III wells, and some
Class V injection wells subject to the requirement to obtain an Underground Injection Control (UIC) permit as described at 40
CFR 144.31 and others directed by a UIC official to apply for a UIC permit. Please note that the information needs vary by well
class. These instructions are specific to Class I wells; other versions are available for other well classes. Please note that this
form must be signed by a responsible entity as described at 40 CFR 144.32, even if the attachments are prepared by
contractors or service companies. If the application covers multiple wells, use additional pages as necessary to provide all the
requested information.
I. OWNER NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP code of
the owner of the well, well field, or company. Also provide an email address (if available) and/or a phone number.
II. OPERATOR NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP
code of the operator of well or well field; also provide an email address (if available) and/or a phone number. If the operator is
the same as the owner, enter “same as owner.”
III. COMMERCIAL FACILITY: Check the appropriate box to indicate the type of facility. A commercial facility is a single or
multiple well facility that is specifically engaged in the business of injecting waste fluids generated by third party producers that
is originated off-site and transported to the facility by truck for a fee or compensation.
IV. OWNERSHIP: Check the appropriate box to indicate whether the owner of the well/facility is a private, Federal, or
State/Tribal/Municipal entity.
V. TYPE OF PERMIT ACTION REQUESTED: Check “new permit” if the well has never been subject to a UIC permit (e.g., for
a newly constructed or converted well). Check “permit renewal” for an application associated with extending an expiring UIC
permit. Check “modification” for an application to modify an existing permit that is not expiring. Check “add well to area permit”
if additional wells are to be covered under an existing UIC area permit. Check “other,” if needed and describe the situation.
VI. 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. A list of SIC codes is available from the U.S. Department of Labor at
https://www.osha.gov/pls/imis/sicsearch.html.
VII. INDIAN COUNTRY: Check yes if the well is located in Indian country. Indian country (as defined in 18 U.S.C. 1151)
includes: all land within the limits of any Indian reservation under the jurisdiction of the U.S. government; all dependent Indian
communities within the borders of the U.S.; and all Indian allotments, the Indian titles to which have not been extinguished.
VIII. TYPE OF PERMIT: Check “Individual” or “Area” to indicate the type of permit requested. Individual permits cover a single
injection well, while area permits may cover more than one injection well. Note that area permits are issued at the discretion of
the Director and that wells covered by an area permit must: be at one contiguous site, be under the control of one entity, and
may not inject hazardous waste. If an area permit is requested, enter the number of wells to be included in the permit. In the
case of a project or field that crosses State lines, it may be possible to consider an area permit if EPA has jurisdiction in all
affected States (each such case will be considered individually). Also provide the name of the well field or project.
IX. CLASS AND TYPE OF WELL: Enter the class (as defined in 40 CFR 144.6) and type of injection well for which a permit is
requested. Use the most pertinent code selected from the table below. When selecting type “X”, please explain in the space
provided.
TABLE OF CLASS I WELL TYPES
I
M
H
R
X

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 (not included in Type “I,” “M,” “H,” or “R”).

X. WELL STATUS: Check Box A, Operating if the well currently operates as an injection well (e.g., if a permit renewal is
requested or a permit is sought for an existing rule-authorized injection well). Check Box B, Conversion for an existing well
not currently being utilized for injection that is proposed to be converted to an injection well. Check Box C, Proposed for an
underground injection well not yet constructed or completed. Provide relevant dates if A or B are checked.
XI. WELL INFORMATION: Enter the API number (the number assigned by the local jurisdiction (usually a State Oil and Gas
Agency) using the American Petroleum Institute standard numbering system). Enter the Permit or EPA ID number assigned
to the injection well by the EPA or the permitting authority. If you do not have a number (e.g., for a new well), this will be
provided by EPA or the permitting authority, and you can leave the field blank. Also enter the Full Name of the Well or
project.
XII. LOCATION: For individual permit applications, in the fields provided, enter the location of the well using latitude and
longitude and/or the Public Land Survey System. When using latitude and longitude, use decimal degrees to five or six places

after the decimal, if possible; be sure to include a negative sign for the longitude of a well in the Western Hemisphere and a
negative sign for the latitude of a well in the Southern Hemisphere. When using the Public Land Survey System, fill in the
complete township, range, and section to the nearest quarter-quarter section. A township is north or south of the baseline, and
a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the distance, in feet, from the nearest north
or south line and nearest east or west line of the quarter-section. For area permit applications, provide the latitude and
longitude of the approximate center of the area.
XIII. ATTACHMENTS: Specific instructions for completing the attachments are presented on pages 3 through 6. Place the
permit or EPA ID number (or, if none has been assigned, other identifying information such as an API number or the project
name) in the upper right hand corner of each page of the attachments.
XIV. CERTIFICATION: All permit applications must be signed by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency.

PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information is
estimated to average 215 hours per response for a Class I hazardous well permit application and 104 hours per response for a
Class I non-hazardous well permit 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 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.

Instructions for Completing Attachments to Form 7520-6 (Class I Wells)
The Underground Injection Control (UIC) program, as promulgated under the Safe Drinking Water Act (SDWA), is designed to
prevent injection activity from allowing the movement of fluid containing any contaminant into underground sources of drinking
water (USDWs), if the presence of that contaminant may cause a violation of any primary drinking water regulation or may
otherwise adversely affect the health of persons as found at Title 40 of the Code of Federal Regulations (40 CFR) section
144.12. Any applicant for a permit under this program shall have the burden of showing that their proposed construction,
operation, maintenance, conversion, plugging, abandonment, and injection activity, does not endanger USDWs.
The attachments below have been constructed to provide applicants with clear expectations as to what information EPA needs
to make a determination that an applicant’s proposed activities will not endanger USDWs.
Pre-Application Coordination
Coordination between the UIC program and the permit applicant prior to submittal of the permit application is an important step
for efficient and effective permitting. Early discussions will ensure that the applicant is aware of all the permit application
requirements, including state specific requirements found at 40 CFR part 147. These discussions may also help the applicant
plan how to invest time and resources needed to develop a comprehensive and complete permit application.
Applicants are encouraged to contact their EPA regional UIC program for a pre-application coordination meeting.
When completing each attachment, please be sure to specify the units reported, e.g., of depth, pressure, temperature, etc.
Attachment A. Map(s) and Area of Review
Part I. Well Location(s)
For Individual Permits: If the surface location provided in the accompanying 7520-6 form does not adequately describe the
well location (i.e., due to deviation, directional, or horizontal drilling), please describe the well’s orientation and provide the
top- and bottom-hole coordinates, as appropriate. If any monitoring wells are proposed as part of this permit application,
provide coordinates for all monitoring wells.
For Area Permits (40 CFR § 144.33): Provide information similar to what is outlined above for individual permits for each
well (existing or proposed) to be covered by this permit. In addition, provide a description of the proposed permitted area.
At a minimum, this area should include all the proposed or existing wells known at the time of permit application submittal.
For circular areas, this description should consist of a defined-radius from a singular point whose coordinates have been
given. For polygonal areas, use a series of coordinates describing the vertices or corners of the area. Submit a
Geographic Information System (GIS) file, if available.
Part II. Area of Review Size Determination (40 CFR § 146.6)
For All Permits. Give the method (fixed radius or equation) and, if appropriate, all calculations used to determine the size
of the area of review (AOR). If you are uncertain as to which method to use, consult with your regional EPA office.
The AOR must be a minimum radius of one-fourth (1/4) mile from the well bore, including a well’s lateral, or the proposed
area permit boundary for area permits, unless the use of an equation is approved by the Director. For Class I wells
injecting hazardous waste, the area of review must be at least a two (2) mile radius around the well bore.
Part III. Map(s) (40 CFR §§ 144.31, 146.14, & 146.70)
Submit a topographic map (or other map if a topographic map is unavailable) extending one mile beyond the facility
property boundary showing:






project injection well(s), well pad(s) and/or project area,
applicable area of review,
all outcrops of injection and confining formations,
all surface water intake and discharge structures, and
all hazardous waste treatment, storage, or disposal facilities.

Consult with your EPA regional office for the definition of the facility property boundary.
Within the one-fourth (1/4) mile beyond the facility property boundary or the AOR, whichever is larger, the map will also
show the:





name and location of all production wells, injection wells, abandoned wells, dry holes, and all water wells, noting their
types (public water system, domestic drinking water, stock, etc.),
springs and surface bodies of water,
mines (surface and subsurface) and quarries, and
other pertinent surface features, including residences, schools, hospitals, and roads.

Only information of public record is required to be included on this map. Multiple maps may be needed to display this
information clearly. If a certain feature is not present in the area covered, please state so definitively (e.g., “There are no
known outcrops of the confining formation in the mapped area”).

Part IV. Area of Review Wells and Corrective Action Plans (40 CFR §§ 144.55, 146.14, & 146.70)
Submit a tabulation of data and wellbore diagrams reasonably available from public records or otherwise known to the
applicant on all wells within the AOR included on the map, which penetrate the proposed confining zone(s). Such
information will include:







well name, location and depth,
well type,
date well was drilled,
well construction that includes casing and cement details, including demonstrated or calculated top of cement,
cement bond logs (if available), and
record of well completion and plugging (if applicable).

For such wells which are improperly sealed, completed, or abandoned, also submit a plan consisting of such steps or
modifications as are necessary to prevent movement of fluid into USDWs.
Part V. Landowner Information (40 CFR § 144.31 and part 147)
Identify and submit a list with the names and addresses of all owners of record of land within one- fourth (1/4) mile of the
facility property boundary. This requirement may be waived by the Regional Administrator if the site is in a populous area
and the Regional Administrator determines that the requirement would be impracticable.
Consult with your regional EPA office, as additional state landowner notification requirements may apply (40 CFR part
147).
Attachment B. Geological and Geophysical Information
Part I. Geological Data (40 CFR §§ 146.14 & 146.70)
Provide the following information:









geological data on all formations from the surface to the base of the injection well, identifying all USDWs and
confining and injection zone(s). This data includes the lithologic description, geological name, thickness, depth, and
total dissolved solids (TDS) concentrations from these formations (if known),
the position of all USDWs that may be affected by the proposed injection relative to the injection formation and the
direction of water movement,
the geologic structure of the local area,
source of information for the geologic data and formation TDS,
porosity and permeability of injection formation (if available),
geological cross-sections proximate to the injection well that include the confining and injection zones. The crosssections should illustrate the regional geologic setting and show the thickness and lateral continuity of the confining
zone(s) through the area of review,
within the AOR, identify known or suspected faults and fracture systems. If identified, provide proximity to the
injection zone and the effect the fault/fracture system may have on the injection activities, and
a history of seismic activity in the area and proximity to crystalline (i.e., granitic) basement.

Part II. Proposed Formation Testing Program (40 CFR §§ 146.12 & 146.70)
Provide a formation testing program to obtain data on:






fluid pressure,
temperature,
estimated fracture pressure,
physical and chemical characteristics of the formation fluids, and
physical, chemical, and radiological characteristics of the injection zone (and, for Class I hazardous wells, of the
confining zone).

Attachment C. Well Construction/Conversion Information
Part I. Well Schematic Diagram (40 CFR §§ 146.14 & 146.70)
Provide a detailed proposed well schematic diagram that includes:







identification of USDWs and confining and injection zones,
casing and cementing details, including demonstrated or calculated top of cement,
tubing and packer (if applicable; if an alternative to a packer is proposed, provide justifying information),
open hole or perforated intervals,
proposed injection procedures including pump, surge, tank, and
surface trace (if horizontal or deviated well).

For wells that are drilled and to be converted to an injection well, also provide the current well schematic diagram.

Part II. Well Construction or Conversion Procedures (40 CFR §§ 144.52, 146.12, 146.14, 146.65 & 146.70)
Provide a detailed description of well construction or conversion procedures, that includes:




proposed logs and other tests conducted during the drilling and construction of new well(s),
proposed stimulation plan(s), if planned, and
description of alarms and shut-down systems at the well (if applicable).

For wells that are drilled and to be converted to an injection well, also provide:



well completion and cementing records, and
previously run logs/tests.

Attachment D. Injection Operation and Monitoring Program (40 CFR §§ 146.13, 146.14, 146.68, & 146.70)
Submit the following information:






flow diagram of fluid flow through the facility,
contingency plan(s) to cope with well failure, so as to prevent migration of contaminating fluids into a USDW,
drawing of the surface construction,
locations of all monitoring devices (show on the map(s) referenced in section A.III. above), and
description of sampling and monitoring devices to monitor the nature of the injected fluids, injection pressure, annulus
pressure (if applicable), flowrate, and cumulative volume.

Additionally, submit the following proposed operating data for each well in the individual or area permit:






average and maximum daily rate and volume of fluids to be injected,
average and maximum injection pressure,
source(s) of injection fluids (including field and formation names),
proposed annular fluid, and
analysis of the chemical, physical, radiological, and biological characteristics, including density and corrosiveness, of
the injection fluid. At a minimum, this should include pH, specific gravity, TDS, and conductivity. Consult with the
regional EPA office for additional guidance.

Attachment E. Plugging and Abandonment Plan (40 CFR §§ 144.31, 144.51, 146.14, & 146.71)
Submit a plugging and abandonment (P&A) plan of the well on EPA Form 7520-19 along with a P&A diagram. The plan
should include:





type, and number of plugs to be used,
placement of each plug including the elevation of top and bottom,
type, grade, and quantity of cement to be used, and
method of placement of the plugs.

Provide one or more cost estimates from an independent firm in the business of plugging and abandoning wells to
conduct the work proposed in the P&A plan for EPA to contract plugging of the well. This is to ensure that EPA has
adequate funding to plug the well(s) if the operator is unable to plug the well(s).
Consult with the regional EPA office for additional guidance on developing the P&A plan and cost estimate calculations.
Attachment F. Financial Assurance (40 CFR § 144.52)
Submit evidence of financial resources, such as a surety bond or financial statement, necessary for a third party to close,
plug, or abandon the well (and, for wells injecting hazardous waste, to perform post-closure care) in the event an owner or
operator is unable to do so. The monetary amount is based on the P&A plan cost estimate provided in Attachment E.
Attachment G. Site Security and Manifest Requirements (Commercial Wells Only)
Provide a proposed site security plan. This could include fencing around the perimeter of the facility. Consult with the
regional EPA office for additional guidance on manifest requirements.
Attachment H Aquifer Exemptions (40 CFR §§ 144.7 & 146.4)
If an aquifer exemption (AE) is requested, submit the information required at 40 CFR § 144.7 and to demonstrate that the
criteria found at 40 CFR § 146.4 are met. Consult with your regional EPA office for additional guidance.

Attachment I. Existing EPA Permits (40 CFR § 144.31)
Submit a listing of all permits or construction approvals received or applied for under any of the following programs:










Hazardous Waste Management program under RCRA,
UIC program under SDWA,
NPDES program under CWA,
Prevention of Significant Deterioration (PSD) program under the Clean Air Act,
Nonattainment program under the Clean Air Act,
National Emission Standards for Hazardous Pollutants (NESHAPS) preconstruction approval under the Clean Air Act.
Ocean dumping permits under the Marine Protection Research and Sanctuaries Act,
Dredge and fill permits under section 404 of CWA, and
Other relevant environmental permits, including State permits.

Attachment J. Description of Business (40 CFR § 144.31)
Provide a brief description of the nature of the business.
Attachment K. Optional Additional Project Information (40 CFR § 144.4)
The following is a list of Federal laws that may apply prior to the issuance of permits. When any of these laws are
applicable, EPA must ensure that they are followed. The optional additional information requested below will assist EPA in
its analyses to satisfy these laws.


The Wild and Scenic Rivers Act, 16 U.S.C. 1273 et seq.
Identify any national wild and scenic river that may be impacted by the activities associated with the proposed project.



The National Historic Preservation Act of 1966, 16 U.S.C. 470 et seq.
Identify properties listed or eligible for listing in the National Register of Historic Places that may be affected by the
activities associated with the proposed project. If previous historic and cultural resource survey(s) have been
conducted, provide the results of the survey(s).



The Endangered Species Act, 16 U.S.C. 1531 et seq.
Identify any endangered or threatened species that may be affected by the activities associated with the proposed
project. If a previous endangered or threatened species survey has been conducted, provide the results of the
survey.



The Coastal Zone Management Act, 16 U.S.C. 1451 et seq.
Identify any coastal zones that may be affected by the activities associated with the proposed project.

This page is intentionally blank. 

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

Approval Expires 11/30/2014

For Official Use Only
Date Received

Underground Injection Control

Permit Application for a Class II Well
(Collected under the authority of the Safe Drinking Water Act.
Sections 1421, 1422, and 40 CFR Part 144)

Permit Number

Read Attached Instructions Before Starting
I. Owner Name, Address, Phone Number and/or Email

III. Commercial Facility

IV. Ownership

II. Operator Name, Address, Phone Number and/or Email

V. Permit Action Requested

VI. SIC Code(s)

VII. Indian Country

Yes

Private

New Permit

Yes

No

Federal

Permit Renewal

No

State/Tribal/
Municipal

Modification
Add Well to Area Permit
Other

VIII. Type of Permit (For multiple wells, use additional page(s) to provide the information requested for each additional well)
A. Individual

Number of Wells

Well Field and/or Project Names

B. Area
IX. Class and Type of Well (see reverse)
A. Class

B. Type (enter code(s))

C. If type code is "X," explain.

X. Well Status

XI. Well Information

A. Operating
Date Injection Started

B. Conversion
Date Well Constructed

API Number

C. Proposed

Permit (or EPA ID) Number
Full Well Name

XII. Location of Well or, for Multiple Wells, Approximate Center of Field or Project
Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location
1/4 of

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Range

Latitude
Longitude

XIII. Attachments

In addition to this form, complete Attachments A-U (as appropriate for the specific well
class) on separate sheets. Submit complete information, as required in the instructions and
list all attachments, maps or other figures, by the applicable letter.
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)
Name and Official Title

(Please Type or Print)

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

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520-6 (CLASS II WELLS)
A permit application must be completed by all owners or operators of current or proposed Class I, II, and III wells, and some
Class V injection wells subject to the requirement to obtain an Underground Injection Control (UIC) permit as described at 40
CFR 144.31 and others directed by a UIC official to apply for a UIC permit. Please note that the information needs vary by well
class. These instructions are specific to Class III wells; other versions are available for other well classes. Please note that this
form must be signed by a responsible entity as described at 40 CFR 144.32, even if the attachments are prepared by
contractors or service companies. If the application covers multiple wells, use additional pages as necessary to provide all the
requested information.
I. OWNER NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP code of
the owner of the well, well field, or company. Also provide an email address (if available) and/or a phone number.
II. OPERATOR NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP
code of the operator of well or well field; also provide an email address (if available) and/or a phone number. If the operator is
the same as the owner, enter “same as owner.”
III. COMMERCIAL FACILITY: Check the appropriate box to indicate the type of facility. A commercial facility is a single or
multiple well facility that is specifically engaged in the business of injecting waste fluids generated by third party producers that
is originated off-site and transported to the facility by truck for a fee or compensation.
IV. OWNERSHIP: Check the appropriate box to indicate whether the owner of the well/facility is a private, Federal, or
State/Tribal/Municipal entity.
V. TYPE OF PERMIT ACTION REQUESTED: Check “new permit” if the well has never been subject to a UIC permit (e.g., for
a newly constructed or converted well). Check “permit renewal” for an application associated with extending an expiring UIC
permit. Check “modification” for an application to modify an existing permit that is not expiring. Check “add well to area permit”
if additional wells are to be covered under an existing UIC area permit. Check “other,” if needed and describe the situation.
VI. 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. A list of SIC codes is available from the U.S. Department of Labor at
https://www.osha.gov/pls/imis/sicsearch.html.
VII. INDIAN COUNTRY: Check yes if the well is located in Indian country. Indian country (as defined in 18 U.S.C. 1151)
includes: all land within the limits of any Indian reservation under the jurisdiction of the U.S. government; all dependent Indian
communities within the borders of the U.S.; and all Indian allotments, the Indian titles to which have not been extinguished.
VIII. TYPE OF PERMIT: Check “Individual” or “Area” to indicate the type of permit requested. Individual permits cover a single
injection well, while area permits may cover more than one injection well. Note that area permits are issued at the discretion of
the Director and that wells covered by an area permit must: be at one contiguous site, be under the control of one entity, and
may not inject hazardous waste. If an area permit is requested, enter the number of wells to be included in the permit. In the
case of a project or field that crosses State lines, it may be possible to consider an area permit if EPA has jurisdiction in all
affected States (each such case will be considered individually). Also provide the name of the well field or project.
IX. CLASS AND TYPE OF WELL: Enter the class (as defined in 40 CFR 144.6) and type of injection well for which a permit is
requested. Use the most pertinent code selected from the table below. When selecting type “X”, please explain in the space
provided.
TABLE OF CLASS II WELL TYPES
A
Annular Disposal Well.
D
Produced Fluid Disposal Well.
H
Hydrocarbon Storage Well (excluding natural gas).
R
Enhanced Recovery Well.
X
Other Class II Wells (not included in Type “A,” “D,” “H,” or “R”).

X. WELL STATUS: Check Box A, Operating if the well currently operates as an injection well (e.g., if a permit renewal is
requested or a permit is sought for an existing rule-authorized injection well). Check Box B, Conversion for an existing well
not currently being utilized for injection that is proposed to be converted to an injection well. Check Box C, Proposed for an
underground injection well not yet constructed or completed. Provide relevant dates if A or B are checked.
XI. WELL INFORMATION: Enter the API number (the number assigned by the local jurisdiction (usually a State Oil and Gas
Agency) using the American Petroleum Institute standard numbering system). Enter the Permit or EPA ID number assigned
to the injection well by the EPA or the permitting authority. If you do not have a number (e.g., for a new well), this will be
provided by EPA or the permitting authority, and you can leave the field blank. Also enter the Full Name of the Well or
project.
XII. LOCATION: For individual permit applications, in the fields provided, enter the location of the well using latitude and
longitude and/or the Public Land Survey System. When using latitude and longitude, use decimal degrees to five or six places
after the decimal, if possible; be sure to include a negative sign for the longitude of a well in the Western Hemisphere and a

negative sign for the latitude of a well in the Southern Hemisphere. When using the Public Land Survey System, fill in the
complete township, range, and section to the nearest quarter-quarter section. A township is north or south of the baseline, and
a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the distance, in feet, from the nearest north
or south line and nearest east or west line of the quarter-section. For area permit applications, provide the latitude and
longitude of the approximate center of the area.
XIII. ATTACHMENTS: Specific instructions for completing the attachments are presented on pages 3 through 6. Place the
permit or EPA ID number (or, if none has been assigned, other identifying information such as an API number or the project
name) in the upper right hand corner of each page of the attachments.
XIV. CERTIFICATION: All permit applications must be signed by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency, or a duly authorized representative of that person.

PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information is
estimated to average 61 hours per response for a Class II well permit 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 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.

Instructions for Completing Attachments to Form 7520-6 (Class II Wells)
The Underground Injection Control (UIC) program, as promulgated under the Safe Drinking Water Act (SDWA), is designed to
prevent injection activity from allowing the movement of fluid containing any contaminant into underground sources of drinking
water (USDWs), if the presence of that contaminant may cause a violation of any primary drinking water regulation or may
otherwise adversely affect the health of persons as found at Title 40 of the Code of Federal Regulations (40 CFR) section
144.12. Any applicant for a permit under this program shall have the burden of showing that their proposed construction,
operation, maintenance, conversion, plugging, abandonment, and injection activity, does not endanger USDWs.
The attachments below have been constructed to provide applicants with clear expectations as to what information EPA needs
to make a determination that an applicant’s proposed activities will not endanger USDWs.
Pre-Application Coordination
Coordination between the UIC program and the permit applicant prior to submittal of the permit application is an important step
for efficient and effective permitting. Early discussions will ensure that the applicant is aware of all the permit application
requirements, including state specific requirements found at 40 CFR part 147. These discussions may also help the applicant
plan how to invest time and resources needed to develop a comprehensive and complete permit application.
Applicants are encouraged to contact their EPA regional UIC program for a pre-application coordination meeting.
Note: If the owner or operator of existing rule authorized Class II UIC well(s) is required by the EPA to apply for a permit (40
CFR § 144.25), consult with EPA staff during the pre-application coordination for additional requirements that may apply.
When completing each attachment, please be sure to specify the units reported, e.g., of depth, pressure, temperature, etc.
Attachment A.

Map(s) and Area of Review

Part I. Well Location(s)
For Individual Permits: If the surface location provided in the accompanying 7520-6 form does not adequately describe the
well location (i.e., due to deviation, directional, or horizontal drilling), please describe the well’s orientation and provide the
top- and bottom-hole coordinates, as appropriate. If any monitoring wells are proposed as part of this permit application,
provide coordinates for all monitoring wells.
For Area Permits (40 CFR § 144.33): Provide information similar to what is outlined above for individual permits for each
well (existing or proposed) to be covered by this permit. In addition, provide a description of the proposed permitted area.
At a minimum, this area should include all the proposed or existing wells known at the time of permit application submittal.
For circular areas, this description should consist of a defined-radius from a singular point whose coordinates have been
given. For polygonal areas, use a series of coordinates describing the vertices or corners of the area. Submit a
Geographic Information System (GIS) file, if available.
Part II. Area of Review Size Determination (40 CFR § 146.6)
For All Permits. Give the method (fixed radius or equation) and, if appropriate, all calculations used to determine the size
of the area of review (AOR). If you are uncertain as to which method to use, consult with your regional EPA office.
The AOR must be a minimum radius of one-fourth (1/4) mile from the well bore, including a well’s lateral, or the proposed
area permit boundary for area permits, unless the use of an equation is approved by the Director.
In addition, for Class II enhanced oil recovery well(s). The AOR will be at a minimum the larger of the following: one-fourth
(1/4) mile radius or the distance to the nearest active producer in the production formation.
Part III. Map(s) (40 CFR §§ 144.31 & 146.24)
Submit a topographic map (or other map if a topographic map is unavailable) extending one mile beyond the facility
property boundary showing:






project injection well(s), well pad(s) and/or project area,
applicable area of review,
all outcrops of injection and confining formations,
all surface water intake and discharge structures, and
all hazardous waste treatment, storage, or disposal facilities.

Consult with your EPA regional office for the definition of the facility property boundary.
The information below does not apply to existing rule authorized Class II well(s).
Within the one-fourth (1/4) mile beyond the facility property boundary or the AOR, whichever is larger, the map will also
show the:


name and location of all production wells, injection wells, abandoned wells, dry holes, and all water wells, noting their
types (public water system, domestic drinking water, stock, etc.),





springs and surface bodies of water,
mines (surface and subsurface) and quarries, and
other pertinent surface features, including residences, schools, hospitals, and roads.

Only information of public record and pertinent information known to the applicant is required to be included on this map.
Multiple maps may be needed to display this information clearly. If a certain feature is not present in the area covered,
please state so definitively (e.g., “There are no known outcrops of the confining formation in the mapped area.”).
Part IV, below does not apply to existing rule authorized Class II well(s).
Part IV. Area of Review Wells and Corrective Action Plans (40 CFR §§ 144.55 & 146.24)
Submit a tabulation of data and wellbore diagrams reasonably available from public records or otherwise known to the
applicant on all wells within the AOR included on the map, which penetrate the proposed confining zone(s). Such
information will include:







well name, location and depth,
well type,
date well was drilled,
well construction that includes casing and cement details, including demonstrated or calculated top of cement,
cement bond logs (if available), and
record of well completion and plugging (if applicable).

For such wells which are improperly sealed, completed, or abandoned, also submit a plan consisting of such steps or
modifications as are necessary to prevent movement of fluid into USDWs.
Part V. Landowners Information (40 CFR § 144.31 and part 147)
Identify and submit a list with the names and addresses of all owners of record of land within one-fourth (1/4) mile of the
facility property boundary. This requirement may be waived by the Regional Administrator if the site is in a populous area
and the Regional Administrator determines that the requirement would be impracticable.
Consult with your regional EPA office, as additional state landowner notification requirements may apply (40 CFR part
147).
Attachment B.

Geological and Geophysical Information

Part I. Geological Data (40 CFR § 146.24)
Provide the following information:







geological data on all formations from the surface to the base of the injection well, identifying all USDWs and
confining and injection zone(s). This data includes the lithologic description, geological name, thickness, depth, and
total dissolved solids (TDS) concentrations from these formations (if known),
source of information for the geologic data and formation TDS,
porosity and permeability of injection formation (if available),
geological cross-sections (if available) proximate to the injection well that includes the confining and injection zones.
The cross-sections should illustrate the regional geologic setting and show the thickness and lateral continuity of the
confining zone(s) through the area of review,
within the AOR, identify known or suspected faults and fracture systems. If identified, provide proximity to the
injection zone and the effect the fault/fracture system may have on the injection activities, and
a history of seismic activity in the area and proximity to crystalline (i.e., granitic) basement.

Part II. Proposed Formation Testing Program (40 CFR § 146.22)
Provide a formation testing program to obtain data on:




fluid pressure,
estimated fracture pressure, and
physical and chemical characteristics of the injection zone.

Attachment C.

Well Construction/Conversion Information

Part I. Well Schematic Diagram (40 CFR § 146.24)
Provide a detailed proposed well schematic diagram that includes:





identification of USDWs and confining and injection zones,
casing and cementing details, including demonstrated or calculated top of cement,
tubing and packer (if applicable),
open hole or perforated intervals, and



surface trace (if horizontal or deviated well).

For wells that are drilled and to be converted to an injection well, also provide the current well schematic diagram.
Part II. Well Construction or Conversion Procedures (40 CFR §§ 144.52, 146.22, & 146.24)
Provide detailed description of well construction or conversion procedures, that includes:




proposed logs and other tests conducted during the drilling and construction of new well(s),
proposed stimulation plan(s), if planned, and
description of alarms and shut-down systems at the well (if applicable).

For wells that are drilled and to be converted to an injection well, also provide:



well completion and cementing records, and
previously run logs/tests.

Attachment D.

Injection Operation and Monitoring Program (40 CFR §§ 146.23 & 146.24)

Submit the following information:






flow diagram of fluid flow through the facility,
contingency plan(s) to cope with well failure, so as to prevent migration of contaminating fluids into a USDW,
drawing of the surface construction,
locations of all monitoring devices (show on the map(s) referenced in section A.III. above), and
description of sampling and monitoring devices to monitor the nature of the injected fluids, injection pressure, annulus
pressure (if applicable), flowrate, and cumulative volume.

Hydrocarbon storage and enhanced recovery may be monitored on a field or project basis rather than on an individual
well basis by manifold monitoring. If a manifold monitoring program is utilized, describe details of the monitoring program
and how the program is comparable to individual well monitoring. Also, include on the map in section A.III.B, the
distribution manifold applying injection fluid to all wells in the area, including location of all system monitoring locations.
Additionally, submit the following proposed operating data for each well in the individual or area permit:






average and maximum daily rate and volume of fluids to be injected,
average and maximum injection pressure,
source(s) of injection fluids (including field and formation names),
proposed annular fluid, and
analysis of the chemical and physical characteristics of the injection fluid. At a minimum, this should include pH,
specific gravity, TDS, and conductivity. Consult with the regional EPA office for additional guidance.

Attachment E.

Plugging and Abandonment Plan (40 CFR §§ 144.31, 144.51 & 146.24)

Submit a plugging and abandonment (P&A) plan of the well on EPA Form 7520-19 along with a P&A diagram. The plan
should include:





type, and number of plugs to be used,
placement of each plug including the elevation of top and bottom,
type, grade, and quantity of cement to be used, and
method of placement of the plugs.

Provide one or more cost estimates from an independent firm in the business of plugging and abandoning wells to
conduct the work proposed in the P&A plan for EPA to contract plugging of the well. This is to ensure that EPA has
adequate funding to plug the well(s) if the operator is unable to plug the well(s).
Consult with the regional EPA office for additional guidance on developing the P&A plan and cost estimate calculations.
Attachment F.

Financial Assurance (40 CFR § 144.52)

Submit evidence of financial resources, such as a surety bond or financial statement, necessary for a third party to close,
plug, or abandon the well in the event an owner or operator is unable to do so. The monetary amount is based on the P&A
plan cost estimate provided in Attachment E.
Attachment G.

Site Security and Manifest Requirements (Commercial Wells Only)

Provide a proposed site security plan. This could include fencing around the perimeter of the facility. Consult with the
regional EPA office for additional guidance on manifest requirements.

Attachment H.

Aquifer Exemptions (40 CFR §§ 144.7 & 146.4)

If an aquifer exemption (AE) is requested, submit the information required at 40 CFR § 144.7 and to demonstrate that the
criteria found at 40 CFR § 146.4 are met. Consult with your regional EPA office for additional guidance.
Attachment I.

Existing EPA Permits (40 CFR § 144.31)

Submit a listing of all permits or construction approvals received or applied for under any of the following programs:










Hazardous Waste Management program under RCRA,
UIC program under SDWA,
NPDES program under CWA,
Prevention of Significant Deterioration (PSD) program under the Clean Air Act,
Nonattainment program under the Clean Air Act,
National Emission Standards for Hazardous Pollutants (NESHAPS) preconstruction approval under the Clean Air Act.
Ocean dumping permits under the Marine Protection Research and Sanctuaries Act,
Dredge and fill permits under section 404 of CWA, and
Other relevant environmental permits, including State permits.

Attachment J.

Description of Business (40 CFR § 144.31)

Provide a brief description of the nature of the business.
Attachment K.

Optional Additional Project Information (40 CFR § 144.4)

The following is a list of Federal laws that may apply prior to the issuance of permits. When any of these laws are
applicable, EPA must ensure that they are followed. The optional additional information requested below will assist EPA in
its analyses to satisfy these laws.


The Wild and Scenic Rivers Act, 16 U.S.C. 1273 et seq.
Identify any national wild and scenic river that may be impacted by the activities associated with the proposed project.



The National Historic Preservation Act of 1966, 16 U.S.C. 470 et seq.
Identify properties listed or eligible for listing in the National Register of Historic Places that may be affected by the
activities associated with the proposed project. If previous historic and cultural resource survey(s) have been
conducted, provide the results of the survey(s).



The Endangered Species Act, 16 U.S.C. 1531 et seq.
Identify any endangered or threatened species that may be affected by the activities associated with the proposed
project. If a previous endangered or threatened species survey has been conducted, provide the results of the
survey.



The Coastal Zone Management Act, 16 U.S.C. 1451 et seq.
Identify any coastal zones that may be affected by the activities associated with the proposed project.

This page is intentionally blank. 

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

Approval Expires 11/30/2014

For Official Use Only
Date Received

Underground Injection Control

Permit Application for a Class III Well
(Collected under the authority of the Safe Drinking Water Act.
Sections 1421, 1422, and 40 CFR Part 144)

Permit Number

Read Attached Instructions Before Starting
I. Owner Name, Address, Phone Number and/or Email

III. Commercial Facility

IV. Ownership

II. Operator Name, Address, Phone Number and/or Email

V. Permit Action Requested

VI. SIC Code(s)

VII. Indian Country

Yes

Private

New Permit

Yes

No

Federal

Permit Renewal

No

State/Tribal/
Municipal

Modification
Add Well to Area Permit
Other

VIII. Type of Permit (For multiple wells, use additional page(s) to provide the information requested for each additional well)
A. Individual

Number of Wells

Well Field and/or Project Names

B. Area
IX. Class and Type of Well (see reverse)
A. Class

B. Type (enter code(s))

C. If type code is "X," explain.

X. Well Status

XI. Well Information

A. Operating
Date Injection Started

B. Conversion
Date Well Constructed

API Number

C. Proposed

Permit (or EPA ID) Number
Full Well Name

XII. Location of Well or, for Multiple Wells, Approximate Center of Field or Project
Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location
1/4 of

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Range

Latitude
Longitude

XIII. Attachments

In addition to this form, complete Attachments A-U (as appropriate for the specific well
class) on separate sheets. Submit complete information, as required in the instructions and
list all attachments, maps or other figures, by the applicable letter.
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)
Name and Official Title

(Please Type or Print)

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

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520-6 (CLASS III WELLS)
A permit application must be completed by all owners or operators of current or proposed Class I, II, and III wells, and some
Class V injection wells subject to the requirement to obtain an Underground Injection Control (UIC) permit as described at 40
CFR 144.31 and others directed by a UIC official to apply for a UIC permit. Please note that the information needs vary by well
class. These instructions are specific to Class II wells; other versions are available for other well classes. Please note that this
form must be signed by a responsible entity as described at 40 CFR 144.32, even if the attachments are prepared by
contractors or service companies. If the application covers multiple wells, use additional pages as necessary to provide all the
requested information.
I. OWNER NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP code of
the owner of the well, well field, or company. Also provide an email address (if available) and/or a phone number.
II. OPERATOR NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP
code of the operator of well or well field; also provide an email address (if available) and/or a phone number. If the operator is
the same as the owner, enter “same as owner.”
III. COMMERCIAL FACILITY: Check the appropriate box to indicate the type of facility. A commercial facility is a single or
multiple well facility that is specifically engaged in the business of injecting waste fluids generated by third party producers that
is originated off-site and transported to the facility by truck for a fee or compensation.
IV. OWNERSHIP: Check the appropriate box to indicate whether the owner of the well/facility is a private, Federal, or
State/Tribal/Municipal entity.
V. TYPE OF PERMIT ACTION REQUESTED: Check “new permit” if the well has never been subject to a UIC permit (e.g., for
a newly constructed or converted well). Check “permit renewal” for an application associated with extending an expiring UIC
permit. Check “modification” for an application to modify an existing permit that is not expiring. Check “add well to area permit”
if additional wells are to be covered under an existing UIC area permit. Check “other,” if needed and describe the situation.
VI. 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. A list of SIC codes is available from the U.S. Department of Labor at
https://www.osha.gov/pls/imis/sicsearch.html.
VII. INDIAN COUNTRY: Check yes if the well is located in Indian country. Indian country (as defined in 18 U.S.C. 1151)
includes: all land within the limits of any Indian reservation under the jurisdiction of the U.S. government; all dependent Indian
communities within the borders of the U.S.; and all Indian allotments, the Indian titles to which have not been extinguished.
VIII. TYPE OF PERMIT: Check “Individual” or “Area” to indicate the type of permit requested. Individual permits cover a single
injection well, while area permits may cover more than one injection well. Note that area permits are issued at the discretion of
the Director and that wells covered by an area permit must: be at one contiguous site, be under the control of one entity, and
may not inject hazardous waste. If an area permit is requested, enter the number of wells to be included in the permit. In the
case of a project or field that crosses State lines, it may be possible to consider an area permit if EPA has jurisdiction in all
affected States (each such case will be considered individually). Also provide the name of the well field or project.
IX. CLASS AND TYPE OF WELL: Enter the class (as defined in 40 CFR 144.6) and type of injection well for which a permit is
requested. Use the most pertinent code selected from the table below. When selecting type “X”, please explain in the space
provided.
TABLE OF CLASS III WELL TYPES
G
M
S
T
U
X

In Situ Gasification Well.
Solution Mining Well.
Sulfur Mining Well by Frasch Process.
Geothermal Well.
Uranium Mining Well (excluding solution mining of conventional mines).
Other Class III Wells (not included in Type “G,” “M,” “S,” “T,” “U,” or “X”).

X. WELL STATUS: Check Box A, Operating if the well currently operates as an injection well (e.g., if a permit renewal is
requested or a permit is sought for an existing rule-authorized injection well). Check Box B, Conversion for an existing well
not currently being utilized for injection that is proposed to be converted to an injection well. Check Box C, Proposed for an
underground injection well not yet constructed or completed. Provide relevant dates if A or B are checked.
XI. WELL INFORMATION: Enter the API number (the number assigned by the local jurisdiction (usually a State Oil and Gas
Agency) using the American Petroleum Institute standard numbering system). Enter the Permit or EPA ID number assigned
to the injection well by the EPA or the permitting authority. If you do not have a number (e.g., for a new well), this will be
provided by EPA or the permitting authority, and you can leave the field blank. Also enter the Full Name of the Well or
project.
XII. LOCATION: For individual permit applications, in the fields provided, enter the location of the well using latitude and
longitude and/or the Public Land Survey System. When using latitude and longitude, use decimal degrees to five or six places

after the decimal, if possible; be sure to include a negative sign for the longitude of a well in the Western Hemisphere and a
negative sign for the latitude of a well in the Southern Hemisphere. When using the Public Land Survey System, fill in the
complete township, range, and section to the nearest quarter-quarter section. A township is north or south of the baseline, and
a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the distance, in feet, from the nearest north
or south line and nearest east or west line of the quarter-section. For area permit applications, provide the latitude and
longitude of the approximate center of the area.
XIII. ATTACHMENTS: Specific instructions for completing the attachments are presented on pages 3 through 6. Place the
permit or EPA ID number (or, if none has been assigned, other identifying information such as an API number or the project
name) in the upper right hand corner of each page of the attachments.
XIV. CERTIFICATION: All permit applications must be signed by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency.

PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information is
estimated to average 123 hours per response for a Class III well permit 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 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.

Instructions for Completing Attachments to Form 7520-6 (Class III Wells)
The Underground Injection Control (UIC) program, as promulgated under the Safe Drinking Water Act (SDWA), is designed to
prevent injection activity from allowing the movement of fluid containing any contaminant into underground sources of drinking
water (USDWs), if the presence of that contaminant may cause a violation of any primary drinking water regulation or may
otherwise adversely affect the health of persons as found at Title 40 of the Code of Federal Regulations (40 CFR) section
144.12. Any applicant for a permit under this program shall have the burden of showing that their proposed construction,
operation, maintenance, conversion, plugging, abandonment, and injection activity, does not endanger USDWs.
The attachments below have been constructed to provide applicants with clear expectations as to what information EPA needs
to make a determination that an applicant’s proposed activities will not endanger USDWs.
Pre-Application Coordination
Coordination between the UIC program and the permit applicant prior to submittal of the permit application is an important step
for efficient and effective permitting. Early discussions will ensure that the applicant is aware of all the permit application
requirements, including state specific requirements found at 40 CFR part 147. These discussions may also help the applicant
plan how to invest time and resources needed to develop a comprehensive and complete permit application.
Applicants are encouraged to contact their EPA regional UIC program for a pre-application coordination meeting.
When completing each attachment, please be sure to specify the units reported, e.g., of depth, pressure, temperature, etc.
Attachment A. Map(s) and Area of Review
Part I. Well Location(s)
For Individual Permits: If the surface location provided in the accompanying 7520-6 form does not adequately describe the
well location (i.e., due to deviation, directional, or horizontal drilling), please describe the well’s orientation and provide the
top- and bottom-hole coordinates, as appropriate. If any monitoring wells are proposed as part of this permit application,
provide coordinates for all monitoring wells.
For Area Permits (40 CFR § 144.33): Provide information similar to what is outlined above for individual permits for each
well (existing or proposed) to be covered by this permit. In addition, provide a description of the proposed permitted area.
At a minimum, this area should include all the proposed or existing wells known at the time of permit application submittal.
For circular areas, this description should consist of a defined-radius from a singular point whose coordinates have been
given. For polygonal areas, use a series of coordinates describing the vertices or corners of the area. Submit a
Geographic Information System (GIS) file, if available.
Part II. Area of Review Size Determination (40 CFR § 146.6)
For All Permits. Give the method (fixed radius or equation) and, if appropriate, all calculations used to determine the size
of the area of review (AOR). If you are uncertain as to which method to use, consult with your regional EPA office.
The AOR must be a minimum radius of one-fourth (1/4) mile from the well bore, including a well’s lateral, or the proposed
area permit boundary for area permits, unless the use of an equation is approved by the Director.
Part III. Map(s) (40 CFR §§ 144.31 & 146.34)
Submit a topographic map (or other map if a topographic map is unavailable) extending one mile beyond the facility
property showing:






project injection well(s), well pad(s) and/or project area,
applicable area of review,
all outcrops of injection and confining formations,
all surface water intake and discharge structures, and
all hazardous waste treatment, storage, or disposal facilities.

Consult with your EPA regional office for the definition of the facility property boundary.
Within the one-fourth (1/4) mile beyond the facility property boundary or the AOR, whichever is larger, the map will also
show the:





name and location of all production wells, injection wells, abandoned wells, dry holes, and all water wells, noting their
types (public water system, domestic drinking water, stock, etc.),
springs and surface bodies of water,
mines (surface and subsurface) and quarries, and
other pertinent surface features, including residences, schools, hospitals, and roads.

Only information of public record and pertinent information known to the applicant is required to be included on this map.
Multiple maps may be needed to display this information clearly. If a certain feature is not present in the area covered,
please state so definitively (e.g., “There are no known outcrops of the confining formation in the mapped area.”).
Part IV. Area of Review Wells and Corrective Action Plans (40 CFR §§ 144.55 & 146.34)
Submit a tabulation of data and wellbore diagrams reasonably available from public records or otherwise known to the
applicant on all wells within the AOR included on the map, which penetrate the proposed confining zone(s). Such
information will include:







well name, location and depth,
well type,
date well was drilled,
well construction that includes casing and cement details, including demonstrated or calculated top of cement,
cement bond logs (if available), and
record of well completion and plugging (if applicable).

For such wells which are improperly sealed, completed, or abandoned, also submit a plan consisting of such steps or
modifications as are necessary to prevent movement of fluid into USDWs.
Part V. Landowners Information (40 CFR § 144.31 and part 147)
Identify and submit a list with the names and addresses of all owners of record of land within one-fourth (1/4) mile of the
facility property boundary. This requirement may be waived by the Regional Administrator if the site is in a populous area
and the Regional Administrator determines that the requirement would be impracticable.
Consult with your regional EPA office, as additional state landowner notification requirements may apply (40 CFR part
147).
Attachment B. Geological and Geophysical Information
Part I. Geological Data (40 CFR § 146.34)
Provide the following information:









geological data on all formations from the surface to the base of the injection well, identifying all USDWs and
confining and injection zone(s). This data includes the lithologic description, geological name, thickness, depth, and
total dissolved solids (TDS) concentrations from these formations (if known),
the position of all USDWs that may be affected by the proposed injection relative to the injection formation and the
direction of water movement,
the geologic structure of the local area,
source of information for the geologic data and formation TDS,
porosity and permeability of injection formation (if available),
geological cross-sections proximate to the injection well that include the confining and injection zones. The crosssections should illustrate the regional geologic setting and show the thickness and lateral continuity of the confining
zone(s) through the area of review,
within the AOR, identify known or suspected faults and fracture systems. If identified, provide proximity to the
injection zone and the effect the fault/fracture system may have on the injection activities, and
a history of seismic activity in the area and proximity to crystalline (i.e., granitic) basement.

Part II. Proposed Formation Testing Program (40 CFR § 146.32)
Where the injection zone is a naturally water-bearing formation, provide a formation testing program to obtain data on:




fluid pressure,
estimated fracture pressure, and
physical and chemical characteristics of the formation fluids.

Where the injection zone is a not water-bearing formation, the testing must be designed to obtain data on fracture
pressure.
Attachment C. Well Construction/Conversion Information
Part I. Well Schematic Diagram (40 CFR § 146.34)
Provide a detailed proposed well schematic diagram that includes:





identification of USDWs and confining and injection zones,
casing and cementing details, including demonstrated or calculated top of cement,
tubing and packer (if applicable),
open hole or perforated intervals,




proposed injection procedures including pump, surge, tank, and
surface trace (if horizontal or deviated well).

For wells that are drilled and to be converted to an injection well, also provide the current well schematic diagram.
Part II. Well Construction or Conversion Procedures (40 CFR §§ 144.52, 146.32, & 146.34)
Provide a detailed description of well construction or conversion procedures, that includes:




proposed logs and other tests conducted during the drilling and construction of new well(s),
proposed stimulation plan(s), if planned, and
description of alarms and shut-down systems at the well (if applicable).

For wells that are drilled and to be converted to an injection well, also provide:



well completion and cementing records, and
previously run logs/tests.

Attachment D. Injection Operation and Monitoring Program (40 CFR §§ 146.33 & 146.34)
Submit the following information:






flow diagram of fluid flow through the facility,
contingency plan(s) to cope with well failure, so as to prevent migration of contaminating fluids into a USDW,
drawing of the surface construction,
locations of all monitoring devices (show on the map(s) referenced in section A.III. above), and
description of sampling and monitoring devices to monitor the nature of the injected fluids, injection pressure, annulus
pressure (if applicable), flowrate, and cumulative volume.

Additionally, submit the following proposed operating data for each well in the individual or area permit:






average and maximum daily rate and volume of fluids to be injected,
average and maximum injection pressure,
source(s) of injection fluids (including field and formation names),
proposed annular fluid, and
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).

Also, discuss any expected changes in pressure, native fluid displacement, and the direction of movement of injection
fluid.
Attachment E. Plugging and Abandonment Plan (40 CFR §§ 144.31, 144.51 & 146.34)
Submit a plugging and abandonment (P&A) plan of the well on EPA Form 7520-19 along with a P&A diagram. The plan
should include:





type, and number of plugs to be used,
placement of each plug including the elevation of top and bottom,
type, grade, and quantity of cement to be used, and
method of placement of the plugs.

Provide one or more cost estimates from an independent firm in the business of plugging and abandoning wells to
conduct the work proposed in the P&A plan for EPA to contract plugging of the well. This is to ensure that EPA has
adequate funding to plug the well(s) if the operator is unable to plug the well(s).
Consult with the regional EPA office for additional guidance on developing the P&A plan and cost estimate calculations.
Attachment F. Financial Assurance (40 CFR § 144.52)
Submit evidence of financial resources, such as a surety bond or financial statement, necessary for a third party to close,
plug, or abandon the well in the event an owner or operator is unable to do so. The monetary amount is based on the P&A
plan cost estimate provided in Attachment E.
Attachment G. Site Security and Manifest Requirements (Commercial Wells Only)
Provide a proposed site security plan. This could include fencing around the perimeter of the facility. Consult with the
regional EPA office for additional guidance on manifest requirements.

Attachment H Aquifer Exemptions (40 CFR §§ 144.7 & 146.4)
If an aquifer exemption (AE) is requested, submit the information required at 40 CFR § 144.7 and to demonstrate that the
criteria found at 40 CFR § 146.4 are met. Consult with your regional EPA office for additional guidance.
Attachment I. Existing EPA Permits (40 CFR § 144.31)
Submit a listing of all permits or construction approvals received or applied for under any of the following programs:










Hazardous Waste Management program under RCRA,
UIC program under SDWA,
NPDES program under CWA,
Prevention of Significant Deterioration (PSD) program under the Clean Air Act,
Nonattainment program under the Clean Air Act,
National Emission Standards for Hazardous Pollutants (NESHAPS) preconstruction approval under the Clean Air Act.
Ocean dumping permits under the Marine Protection Research and Sanctuaries Act,
Dredge and fill permits under section 404 of CWA, and
Other relevant environmental permits, including State permits.

Attachment J. Description of Business (40 CFR § 144.31)
Provide a brief description of the nature of the business.
Attachment K. Optional Additional Project Information (40 CFR § 144.4)
The following is a list of Federal laws that may apply prior to the issuance of permits. When any of these laws are
applicable, EPA must ensure that they are followed. The optional additional information requested below will assist EPA in
its analyses to satisfy these laws.


The Wild and Scenic Rivers Act, 16 U.S.C. 1273 et seq.
Identify any national wild and scenic river that may be impacted by the activities associated with the proposed project.



The National Historic Preservation Act of 1966, 16 U.S.C. 470 et seq.
Identify properties listed or eligible for listing in the National Register of Historic Places that may be affected by the
activities associated with the proposed project. If previous historic and cultural resource survey(s) have been
conducted, provide the results of the survey(s).



The Endangered Species Act, 16 U.S.C. 1531 et seq.
Identify any endangered or threatened species that may be affected by the activities associated with the proposed
project. If a previous endangered or threatened species survey has been conducted, provide the results of the
survey.



The Coastal Zone Management Act, 16 U.S.C. 1451 et seq.
Identify any coastal zones that may be affected by the activities associated with the proposed project.

This page is intentionally blank. 

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

Approval Expires 11/30/2014

For Official Use Only
Date Received

Underground Injection Control

Permit Application for a Class V Well
(Collected under the authority of the Safe Drinking Water Act.
Sections 1421, 1422, and 40 CFR Part 144)

Permit Number

Read Attached Instructions Before Starting
I. Owner Name, Address, Phone Number and/or Email

III. Commercial Facility

IV. Ownership

II. Operator Name, Address, Phone Number and/or Email

V. Permit Action Requested

VI. SIC Code(s)

VII. Indian Country

Yes

Private

New Permit

Yes

No

Federal

Permit Renewal

No

State/Tribal/
Municipal

Modification
Add Well to Area Permit
Other

VIII. Type of Permit (For multiple wells, use additional page(s) to provide the information requested for each additional well)
A. Individual

Number of Wells

Well Field and/or Project Names

B. Area
IX. Class and Type of Well (see reverse)
A. Class

B. Type (enter code(s))

C. If type code is "X," explain.

X. Well Status

XI. Well Information

A. Operating
Date Injection Started

B. Conversion
Date Well Constructed

API Number

C. Proposed

Permit (or EPA ID) Number
Full Well Name

XII. Location of Well or, for Multiple Wells, Approximate Center of Field or Project
Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location
1/4 of

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Range

Latitude
Longitude

XIII. Attachments

In addition to this form, complete Attachments A-U (as appropriate for the specific well
class) on separate sheets. Submit complete information, as required in the instructions and
list all attachments, maps or other figures, by the applicable letter.
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)
Name and Official Title

(Please Type or Print)

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

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520-6 (CLASS V WELLS)
A permit application must be completed by all owners or operators of current or proposed Class I, II, and III wells, and some
Class V injection wells subject to the requirement to obtain an Underground Injection Control (UIC) permit as described at 40
CFR 144.31 and others directed by a UIC official to apply for a UIC permit. Please note that the information needs vary by well
class. These instructions are specific to Class V wells; other versions are available for other well classes. Please note that this
form must be signed by a responsible entity as described at 40 CFR 144.32, even if the attachments are prepared by
contractors or service companies. If the application covers multiple wells, use additional pages as necessary to provide all the
requested information.
I. OWNER NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP code of
the owner of the well, well field, or company. Also provide an email address (if available) and/or a phone number.
II. OPERATOR NAME, ADDRESS, PHONE AND/OR EMAIL: Enter the name and street address, city/town, state, and ZIP
code of the operator of well or well field; also provide an email address (if available) and/or a phone number. If the operator is
the same as the owner, enter “same as owner.”
III. COMMERCIAL FACILITY: Check the appropriate box to indicate the type of facility. A commercial facility is a single or
multiple well facility that is specifically engaged in the business of injecting waste fluids generated by third party producers that
is originated off-site and transported to the facility by truck for a fee or compensation.
IV. OWNERSHIP: Check the appropriate box to indicate whether the owner of the well/facility is a private, Federal, or
State/Tribal/Municipal entity.
V. TYPE OF PERMIT ACTION REQUESTED: Check “new permit” if the well has never been subject to a UIC permit (e.g., for
a newly constructed or converted well). Check “permit renewal” for an application associated with extending an expiring UIC
permit. Check “modification” for an application to modify an existing permit that is not expiring. Check “add well to area permit”
if additional wells are to be covered under an existing UIC area permit. Check “other,” if needed and describe the situation.
VI. 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. A list of SIC codes is available from the U.S. Department of Labor at
https://www.osha.gov/pls/imis/sicsearch.html.
VII. INDIAN COUNTRY: Check yes if the well is located in Indian country. Indian country (as defined in 18 U.S.C. 1151)
includes: all land within the limits of any Indian reservation under the jurisdiction of the U.S. government; all dependent Indian
communities within the borders of the U.S.; and all Indian allotments, the Indian titles to which have not been extinguished.
VIII. TYPE OF PERMIT: Check “Individual” or “Area” to indicate the type of permit requested. Individual permits cover a single
injection well, while area permits may cover more than one injection well. Note that area permits are issued at the discretion of
the Director and that wells covered by an area permit must: be at one contiguous site, be under the control of one entity, and
may not inject hazardous waste. If an area permit is requested, enter the number of wells to be included in the permit. In the
case of a project or field that crosses State lines, it may be possible to consider an area permit if EPA has jurisdiction in all
affected States (each such case will be considered individually). Also provide the name of the well field or project.
IX. CLASS AND TYPE OF WELL: Enter the class (as defined in 40 CFR 144.6) and type of injection well for which a permit is
requested. Use the most pertinent code selected from the table below. When selecting type “X”, please explain in the space
provided.
TABLE OF CLASS V WELL TYPES
A
B
C
D
E
F
G
H
I
J

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

X. WELL STATUS: Check Box A, Operating if the well currently operates as an injection well (e.g., if a permit renewal is
requested or a permit is sought for an existing rule-authorized injection well). Check Box B, Conversion for an existing well
not currently being utilized for injection that is proposed to be converted to an injection well. Check Box C, Proposed for an
underground injection well not yet constructed or completed. Provide relevant dates if A or B are checked.

XI. WELL INFORMATION: Enter the API number (the number assigned by the local jurisdiction (usually a State Oil and Gas
Agency) using the American Petroleum Institute standard numbering system). Enter the Permit or EPA ID number assigned
to the injection well by the EPA or the permitting authority. If you do not have a number (e.g., for a new well), this will be
provided by EPA or the permitting authority, and you can leave the field blank. Also enter the Full Name of the Well or
project.
XII. LOCATION: For individual permit applications, in the fields provided, enter the location of the well using latitude and
longitude and/or the Public Land Survey System. When using latitude and longitude, use decimal degrees to five or six places
after the decimal, if possible; be sure to include a negative sign for the longitude of a well in the Western Hemisphere and a
negative sign for the latitude of a well in the Southern Hemisphere. When using the Public Land Survey System, fill in the
complete township, range, and section to the nearest quarter-quarter section. A township is north or south of the baseline, and
a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the distance, in feet, from the nearest north
or south line and nearest east or west line of the quarter-section. For area permit applications, provide the latitude and
longitude of the approximate center of the area.
XIII. ATTACHMENTS: Specific instructions for completing the attachments are presented on pages 3 through 6. Place the
permit or EPA ID number (or, if none has been assigned, other identifying information such as an API number or the project
name) in the upper right hand corner of each page of the attachments.
XIV. CERTIFICATION: All permit applications must be signed by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency.

PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information is
estimated to average 104 hours per response for a Class V well permit 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 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.

Instructions for Completing Attachments to Form 7520-6 (Class V Wells)
The Underground Injection Control (UIC) program, as promulgated under the Safe Drinking Water Act (SDWA), is designed to
prevent injection activity from allowing the movement of fluid containing any contaminant into underground sources of drinking
water (USDWs), if the presence of that contaminant may cause a violation of any primary drinking water regulation or may
otherwise adversely affect the health of persons as found at Title 40 of the Code of Federal Regulations (40 CFR) section
144.12. Any applicant for a permit under this program shall have the burden of showing that their proposed construction,
operation, maintenance, conversion, plugging, abandonment, and injection activity, does not endanger USDWs.
The attachments below have been constructed to provide applicants with clear expectations as to what information EPA needs
to make a determination that an applicant’s proposed activities will not endanger USDWs.
Pre-Application Coordination
Coordination between the UIC program and the permit applicant prior to submittal of the permit application is an important step
for efficient and effective permitting. Early discussions will ensure that the applicant is aware of all the permit application
requirements, including state specific requirements found at 40 CFR part 147. These discussions may also help the applicant
plan how to invest time and resources needed to develop a comprehensive and complete permit application.
Applicants are encouraged to contact their EPA regional UIC program for a pre-application coordination meeting.
When completing each attachment, please be sure to specify the units reported, e.g., of depth, pressure, temperature, etc.
Attachment A. Map(s) and Area of Review
Part I. Well Location(s)
For Individual Permits: If the surface location provided in the accompanying 7520-6 form does not adequately describe the
well location (i.e., due to deviation, directional, or horizontal drilling), please describe the well’s orientation and provide the
top- and bottom-hole coordinates, as appropriate. If any monitoring wells are proposed as part of this permit application,
provide coordinates for all monitoring wells.
For Area Permits (40 CFR § 144.33): Provide information similar to what is outlined above for individual permits for each
well (existing or proposed) to be covered by this permit. In addition, provide a description of the proposed permitted area.
At a minimum, this area should include all the proposed or existing wells known at the time of permit application submittal.
For circular areas, this description should consist of a defined-radius from a singular point whose coordinates have been
given. For polygonal areas, use a series of coordinates describing the vertices or corners of the area. Submit a
Geographic Information System (GIS) file, if available.
Part II. Area of Review Size Determination (40 CFR § 146.6)
For All Permits. Give the method (fixed radius or equation) and, if appropriate, all calculations used to determine the size
of the area of review (AOR). If you are uncertain as to which method to use, consult with your regional EPA office.
The AOR must be a minimum radius of one-fourth (1/4) mile from the well bore, including a well’s lateral, or the proposed
area permit boundary for area permits, unless the use of an equation is approved by the Director.
Part III. Map(s) (40 CFR § 144.31)
Submit a topographic map (or other map if a topographic map is unavailable) extending one mile beyond the facility
property boundary showing:






project injection well(s), well pad(s) and/or project area,
applicable area of review,
all outcrops of injection and confining formations,
all surface water intake and discharge structures, and
all hazardous waste treatment, storage, or disposal facilities.

Consult with your EPA regional office for the definition of the facility property boundary.
Within the one-fourth (1/4) mile beyond the facility property boundary or the AOR, whichever is larger, the map will also
show the:





name and location of all production wells, injection wells, abandoned wells, dry holes, and all water wells, noting their
types (public water system, domestic drinking water, stock, etc.),
springs and surface bodies of water,
mines (surface and subsurface) and quarries, and
other pertinent surface features, including residences, schools, hospitals, and roads.

Only information of public record and pertinent information known to the applicant is required to be included on this map.
Multiple maps may be needed to display this information clearly. If a certain feature is not present in the area covered,
please state so definitively (e.g., “There are no known outcrops of the confining formation in the mapped area.”).
Part IV. Area of Review Wells and Corrective Action Plans (40 CFR § 144.55)
Submit a tabulation of data and wellbore diagrams reasonably available from public records or otherwise known to the
applicant on all wells within the AOR included on the map, which penetrate the proposed confining zone(s). Such
information will include:







well name, location and depth,
well type,
date well was drilled,
well construction that includes casing and cement details, including demonstrated or calculated top of cement,
cement bond logs (if available), and
record of well completion and plugging (if applicable).

For such wells which are improperly sealed, completed, or abandoned, also submit a plan consisting of such steps or
modifications as are necessary to prevent movement of fluid into USDWs.
Part V. Landowners Information (40 CFR § 144.31 and part 147)
Identify and submit a list with the names and addresses of all owners of record of land within one-fourth (1/4) mile of the
facility property boundary. This requirement may be waived by the Regional Administrator if the site is in a populous area
and the Regional Administrator determines that the requirement would be impracticable.
Consult with your regional EPA office, as additional state landowner notification requirements may apply (40 CFR part
147).
Attachment B. Geological and Geophysical Information
Part I. Geological Data
Provide the following information:









geological data on all formations from the surface to the base of the injection well, identifying all USDWs and
confining and injection zone(s). This data includes the lithologic description, geological name, thickness, depth, and
total dissolved solids (TDS) concentrations from these formations (if known),
the position of all USDWs that may be affected by the proposed injection relative to the injection formation and the
direction of water movement,
the geologic structure of the local area,
source of information for the geologic data and formation TDS,
porosity and permeability of injection formation (if available),
geological cross-sections proximate to the injection well that include the confining and injection zones. The crosssections should illustrate the regional geologic setting and show the thickness and lateral continuity of the confining
zone(s) through the area of review,
within the AOR, identify known or suspected faults and fracture systems. If identified, provide proximity to the
injection zone and the effect the fault/fracture system may have on the injection activities, and
a history of seismic activity in the area and proximity to crystalline (i.e., granitic) basement.

Part II. Proposed Formation Testing Program
Provide a formation testing program to obtain data on:






fluid pressure,
temperature,
estimated fracture pressure,
physical and chemical characteristics of the formation fluids, and
physical and chemical characteristics of the injection zone.

Attachment C. Well Construction/Conversion Information
Part I. Well Schematic Diagram (40 CFR § 144.52)
Provide a detailed proposed well schematic diagram that includes:






identification of USDWs and confining and injection zones,
casing and cementing details, including demonstrated or calculated top of cement,
tubing and packer (if applicable),
open hole or perforated intervals,
proposed injection procedures including pump, surge, tank, and



surface trace (if horizontal or deviated well).

For wells that are drilled and to be converted to an injection well, also provide the current well schematic diagram.
Part II. Well Construction or Conversion Procedures (40 CFR § 144.52)
Provide a detailed description of well construction or conversion procedures, that includes:




proposed logs and other tests conducted during the drilling and construction of new well(s),
proposed stimulation plan(s), if planned, and
description of alarms and shut-down systems at the well (if applicable).

For wells that are drilled and to be converted to an injection well, also provide:



well completion and cementing records, and
previously run logs/tests.

Attachment D. Injection Operation and Monitoring Program (40 CFR § 144.54)
Submit the following information:






flow diagram of fluid flow through the facility,
contingency plan(s) to cope with well failure, so as to prevent migration of contaminating fluids into a USDW,
drawing of the surface construction,
locations of all monitoring devices (show on the map(s) referenced in section A.III. above), and
description of sampling and monitoring devices to monitor the nature of the injected fluids, injection pressure, annulus
pressure (if applicable), flowrate, and cumulative volume.

Additionally, submit the following proposed operating data for each well in the individual or area permit:






average and maximum daily rate and volume of fluids to be injected,
average and maximum injection pressure,
source(s) of injection fluids (including field and formation names),
proposed annular fluid, and
analysis of the chemical and physical characteristics of the injection fluid. At a minimum, this should include pH,
specific gravity, TDS, and conductivity. Consult with the regional EPA office for additional guidance.

Attachment E. Plugging and Abandonment Plan (40 CFR §§ 144.31 & 144.51)
Submit a plugging and abandonment (P&A) plan of the well on EPA Form 7520-19 along with a P&A diagram. The plan
should include:





type, and number of plugs to be used,
placement of each plug including the elevation of top and bottom,
type, grade, and quantity of cement to be used, and
method of placement of the plugs.

Provide one or more cost estimates from an independent firm in the business of plugging and abandoning wells to
conduct the work proposed in the P&A plan for EPA to contract plugging of the well. This is to ensure that EPA has
adequate funding to plug the well(s) if the operator is unable to plug the well(s).
Consult with the regional EPA office for additional guidance on developing the P&A plan and cost estimate calculations.
Attachment F. Financial Assurance (40 CFR § 144.52)
Submit evidence of financial resources, such as a surety bond or financial statement, necessary for a third party to close,
plug, or abandon the well in the event an owner or operator is unable to do so. The monetary amount is based on the P&A
plan cost estimate provided in Attachment E.
Attachment G. Site Security and Manifest Requirements (Commercial Wells Only)
Provide a proposed site security plan. This could include fencing around the perimeter of the facility. Consult with the
regional EPA office for additional guidance on manifest requirements.
Attachment H Aquifer Exemptions (40 CFR §§ 144.7 & 146.4)
If an aquifer exemption (AE) is requested, submit the information required at 40 CFR § 144.7 and to demonstrate that the
criteria found at 40 CFR § 146.4 are met. Consult with your regional EPA office for additional guidance.

Attachment I. Existing EPA Permits (40 CFR § 144.31)
Submit a listing of all permits or construction approvals received or applied for under any of the following programs:










Hazardous Waste Management program under RCRA,
UIC program under SDWA,
NPDES program under CWA,
Prevention of Significant Deterioration (PSD) program under the Clean Air Act,
Nonattainment program under the Clean Air Act,
National Emission Standards for Hazardous Pollutants (NESHAPS) preconstruction approval under the Clean Air Act.
Ocean dumping permits under the Marine Protection Research and Sanctuaries Act,
Dredge and fill permits under section 404 of CWA, and
Other relevant environmental permits, including State permits.

Attachment J. Description of Business (40 CFR § 144.31)
Provide a brief description of the nature of the business.
Attachment K. Optional Additional Project Information (40 CFR § 144.4)
The following is a list of Federal laws that may apply prior to the issuance of permits. When any of these laws are
applicable, EPA must ensure that they are followed. The optional additional information requested below will assist EPA in
its analyses to satisfy these laws.


The Wild and Scenic Rivers Act, 16 U.S.C. 1273 et seq.
Identify any national wild and scenic river that may be impacted by the activities associated with the proposed project.



The National Historic Preservation Act of 1966, 16 U.S.C. 470 et seq.
Identify properties listed or eligible for listing in the National Register of Historic Places that may be affected by the
activities associated with the proposed project. If previous historic and cultural resource survey(s) have been
conducted, provide the results of the survey(s).



The Endangered Species Act, 16 U.S.C. 1531 et seq.
Identify any endangered or threatened species that may be affected by the activities associated with the proposed
project. If a previous endangered or threatened species survey has been conducted, provide the results of the
survey.



The Coastal Zone Management Act, 16 U.S.C. 1451 et seq.
Identify any coastal zones that may be affected by the activities associated with the proposed project.

This page is intentionally blank. 

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency

Application To Transfer Permit/Ownership
Name, Address, Phone Number and/or Email of Existing Permittee

Name, Address, Phone Number and or Email of New Owner

State

County

Well Type
Class I

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location

Class II

1/4 of

Brine Disposal

1/4 of Section

Township

Range

Enhanced Recovery
Hydrocarbon Storage
Class III

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Class V
Latitude

Permit (or EPA ID) Number

Longitude

API Number

Full Well Name

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.

Wellbore Schematic Attached?

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 imprisonmentt.
(Ref. 40 CFR § 144.32)
Name and Official Title of Transferor (Seller)(Please type or print)

Signature

Date Signed

Name and Official Title of Transferee (Buyer)(Please type or print)

Signature

Date Signed

EPA Form 7520-7 (Rev. 12-11)

INSTRUCTIONS FOR FORM 7520-7
This form must be completed by all owners or operators who are seeking to transfer ownership of an injection well that is
permitted under the UIC Program. While reports or other information developed by contractors or service companies may be
attached, this form must be signed by a responsible entity as described at 40 CFR 144.32. If the form covers multiple wells,
use additional pages as necessary to provide all the requested information.
NAME, ADDRESS, PHONE AND/OR EMAIL OF EXISTING PERMITTEE: Enter the name and street address, city/town,
state, and ZIP code of the current owner/permit holder of the well, well field, or company. Also provide an email address (if
available) and/or a phone number.
NAME, ADDRESS, PHONE AND/OR EMAIL OF NEW OWNER: Enter the name and street address, city/town, state, and
ZIP code of the entity to which ownership is being transferred (i.e., the buyer of the well, well field or company). Also provide
an email address (if available) and/or a phone number.
Enter the STATE and COUNTY where the well is located. For States that do not have counties, use the name of that State’s
equivalent jurisdiction at a more local level.
WELL TYPE: Enter the Class (as defined in 40 CFR 144.6) and type of injection well.
WELL LOCATION: Fill in the complete township, range, and section to the nearest quarter-quarter section. A township is
north or south of the baseline, and a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the
distance, in feet, from the nearest north or south line and nearest east or west line of the quarter-section. Also, enter the
latitude and longitude of the well in decimal degrees, to five or six places if possible; be sure to include a negative sign for
the longitude of a well in the Western Hemisphere and a negative sign for the latitude of a well in the Southern Hemisphere.
For an area permit, give the latitude and longitude of the approximate center of the area.
PERMIT OR EPA ID NUMBER: Enter the well identification number or permit number assigned to the injection well by the
EPA or the permitting authority.
API NUMBER: Enter the number assigned by the local jurisdiction (usually a State Oil and Gas Agency) using the American
Petroleum Institute standard numbering system.
FULL WELL NAME: Enter the full name of the well or project. If the facility includes several wells, specify which wells are
being transferred.
ATTACHMENTS: Attach the following items to the completed form: (1) The written agreement between the existing
permittee (i.e., transferor/seller) and the new permittee (i.e., transferee/buyer) containing a specific date for transfer of permit
responsibility, coverage, and liability between them. (2) Evidence of financial responsibility for the new permittee, i.e., a
surety bond, or other adequate assurance, such as financial statements or other materials acceptable to the Director. If a
wellbore schematic for the well being transferred is available, attach it, and check the box on the form.
CERTIFICATION: The transferor (seller) and transferee (buyer) must sign and date the form. This form must be signed by
either: a responsible corporate officer for a corporation, by a general partner for a partnership, by the proprietor of a sole
proprietorship, or by a principal executive or ranking elected official for a public agency.
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information
is estimated to average between 2.9 and 5.8 hours per response, depending on the injection well class. 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.

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency

Quarterly Injection Well Monitoring Report
Month/Year

Month/Year

Month/Year

Injection Pressure (PSI)
1. Minimum
2. Average
3. Maximum
Injection Rate (Barrels/Day)
1. Minimum
2. Average
3. Maximum
Annular Pressure (PSI)
1. Minimum
2. Average
3. Maximum
Injection Volume (Barrels)
1. Monthly Total
2. Yearly Cumulative
Temperature (F °) - If Specified in UIC Permit
1. Minimum
2. Average
3. Maximum
pH - If Specified in UIC Permit
1. Minimum
2. Average
3. Maximum
Other Information Specified in the Permit
(Attach Pages if Necessary)

Permit (or EPA ID) Number

API Number

Full Well Name

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 imprisonmentt. (Ref. 40 CFR § 144.32)
Name and Official Title (Please type or print)

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

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520-8
Use this form to submit quarterly injection well monitoring results. Note: owners or operators of Class II wells should use
Form 7520-11 to report monitoring results. Please submit a separate form for each well.
On the top row, enter the MONTH and YEAR for each month of the quarter for which monitoring results are being reported.
INJECTION PRESSURE: Enter the minimum, average, and maximum injection pressure that occurred during each month,
in pounds per square inch (psi).
INJECTION RATE: Enter the minimum, average, and maximum injection rate, in barrels per day, that occurred during each
month.
ANNULAR PRESSURE: Enter the minimum, average, and maximum pressure on the annulus between the tubing and long
string casing that occurred during each month, in pounds per square inch (psi).
INJECTION VOLUME: Enter the monthly total and yearly cumulative volume (in barrels) that has been injected.
TEMPERATURE: If the UIC permit requires monitoring of the temperature of the injectate, provide the minimum, average,
and maximum temperature that occurred during each month, in degrees Fahrenheit (F°).
pH: If the UIC permit requires monitoring of the pH of the injectate, provide the minimum, average, and maximum values that
occurred during each month.
OTHER INFORMATION: If the UIC permit requires any other monitoring, provide the minimum, average, and maximum
values that occurred during each month, as appropriate. (Attach pages to this form if necessary.)
PERMIT OR EPA ID NUMBER: Enter the well identification number or permit number assigned to the injection well by the
EPA or the permitting authority.
API NUMBER: Enter the number assigned by the local jurisdiction (usually a State Oil and Gas Agency) using the American
Petroleum Institute standard numbering system.
FULL WELL NAME: Enter the full name of the well or project.
CERTIFICATION: This form must be signed and dated by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency.
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information
is estimated to average 24.7 hours per response for operators of Class I hazardous wells, 14.4 hours per response for
operators of Class I non-hazardous wells, and 27.9 hours per response 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.

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency

ANNUAL CLASS II DISPOSAL/INJECTION WELL MONITORING REPORT
Name, Address, Phone and/or Email of Permittee

County

State

WELL TYPE
Brine Disposal
Enhanced Recovery

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location
1/4 of

Hydrocarbon Storage

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Latitude
Permit or EPA ID Number

Longitude
API Number

Full Well Name

TOTAL VOLUME INJECTED

INJECTION PRESSURE
MONTH, YEAR

MAXIMUM PSIG

Range

BBL

MCF

TUBING -- CASING
ANNULUS PRESSURE
(IF SPECIFIED IN PERMIT)
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

INSTRUCTIONS FOR FORM 7520-11
Owners or operators of Class II injection wells should use this form to submit required monitoring data annually. Owners or
operators of all other well classes should use Form 7520-8. Please submit a separate form for each well.
NAME, ADDRESS, PHONE AND/OR EMAIL OF PERMITTEE: Enter the name and street address, city/town, state, and ZIP
code of the permittee. Also provide an email address (if available) and/or a phone number.
Enter the STATE and COUNTY where the well is located. For States that do not have counties, use the name of that State’s
equivalent jurisdiction at a more local level.
Check the appropriate box to describe the WELL TYPE.
WELL LOCATION: Fill in the complete township, range, and section to the nearest quarter-quarter section. A township is
north or south of the baseline, and a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the
distance, in feet, from the nearest north or south line and nearest east or west line of the quarter-section. Also, enter the
latitude and longitude of the well in decimal degrees, to five or six places if possible; be sure to include a negative sign for
the longitude of a well in the Western Hemisphere and a negative sign for the latitude of a well in the Southern Hemisphere.
PERMIT OR EPA ID NUMBER: Enter the well identification number or permit number assigned to the injection well by the
EPA or the permitting authority.
API NUMBER: Enter the number assigned by the local jurisdiction (usually a State Oil and Gas Agency) using the American
Petroleum Institute standard numbering system.
FULL WELL NAME: Enter the full name of the well or project.
Enter on a separate row, each month and year for which monitoring results are reported. Provide the following information:
MAXIMUM INJECTION PRESSURE, in pounds per square inch gauge (psig); TOTAL VOLUME INJECTED in barrels (bbl)
or millions of cubic feet (mcf); and MAXIMUM TUBING-CASING ANNULUS PRESSURE (if specified in the permit) in psig.
CERTIFICATION: This form must be signed and dated by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency.
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information
is estimated to average 29.7 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.

Type or print all information. See reverse for instructions.

OMB No. 2040-0042

1. DATE PREPARED

INVENTORY OF INJECTION WELLS

(Year, Month, Day)

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

Approval Expires 11/30/2014

2. FACILITY ID NUMBER (To be
completed by the permitting authority)

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

3. FACILITY INFORMATION

4. LEGAL CONTACT INFORMATION

NAME, ADDRESS, PHONE NUMBER AND/OR EMAIL

NAME, ADDRESS, ORGANIZATION, PHONE NUMBER AND/OR EMAIL

INDIAN COUNTRY

Yes

No

TYPE

Owner

Operator

5. LOCATIONAL INFORMATION
Surface Location
1/4 of

Latitude
1/4 of

Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Range
Longitude

6. WELL INFORMATION:
A. CLASS
AND
TYPE

B. NUMBER OF WELLS
COMM

NON-COMM

KEY: AC = Active
UC = Under Construction
TA = Temporarily Abandoned

C. TOTAL
NUMBER
OF WELLS

UC

AC

TA

COMMENTS (Optional):
PA

AN

PA = Permanently Abandoned and Approved by State
AN = Permanently Abandoned and not Approved by State

Name and Official Title (Please type or print)

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

D. WELL OPERATION STATUS

Date Submitted

INSTRUCTIONS FOR FORM 7520-16
Use this form to provide inventory information about injection wells regulated under the Underground Injection Control
Program.
DATE PREPARED: Enter date in order of year, month, and day.
FACILITY OR EPA ID NUMBER: This will be completed by EPA or the permitting authority.
NAME, ADDRESS, PHONE AND/OR EMAIL OF FACILITY: Enter the name and street address, city/town, state, and ZIP
code of the facility. Also provide an email address (if available) and/or a phone number.
INDIAN COUNTRY: Check yes if the well is located in Indian country. Indian country (as defined in 18 U.S.C. 1151)
includes: all land within the limits of any Indian reservation under the jurisdiction of the U.S. government; all dependent
Indian communities within the borders of the U.S.; and all Indian allotments, the Indian titles to which have not been
extinguished.
NAME, ADDRESS, PHONE, ORGANIZATION, AND/OR EMAIL OF LEGAL CONTACT: Enter the name and street
address, city/town, state, and ZIP code and the name of the organization to which the legal contact for any questions
regarding the information provided belongs. Also provide an email address (if available) and/or a phone number.
LEGAL CONTACT TYPE: Check the appropriate box to indicate the type of legal contact (i.e., owner or operator). For wells
operated by lease, the operator is the legal contact.
WELL LOCATION: Fill in the complete township, range, and section to the nearest quarter-quarter section. A township is
north or south of the baseline, and a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the
distance, in feet, from the nearest north or south line and nearest east or west line of the quarter-section. Also, enter the
latitude and longitude of the well in decimal degrees, to five or six places if possible; be sure to include a negative sign for
the longitude of a well in the Western Hemisphere and a negative sign for the latitude of a well in the Southern Hemisphere.
For an area permit, give the latitude and longitude of the approximate center of the area.
WELL CLASS AND TYPE: Enter the class (as defined in 40 CFR 144.6) and type of injection well. Use the most pertinent
code selected from the list on the next page. When selecting type X, please explain in the comment space.
NUMBER OF WELLS: Enter the total number of commercial and non-commercial wells of each class/type, as applicable.
A commercial facility is a single or multiple well facility that is specifically engaged in the business of injecting waste fluids
generated by third party producers that is originated off-site and transported to the facility by truck for a fee or compensation.
TOTAL NUMBER OF WELLS: Enter the total number of injection wells of each specified class and type.
WELL OPERATION STATUS: Enter the number of wells under each operation status (use the key on the front of the form).
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information
is estimated to average 0.4 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.

TABLE OF WELL CLASSES AND TYPES
CLASS I: Wells that inject industrial and municipal waste, including hazardous waste, beneath the lowermost
formation containing a USDW.
Type
I
Non-Hazardous Industrial Disposal Well.
M
Non-Hazardous Municipal Disposal Well.
H
Hazardous Waste Disposal Well injecting below the lowermost USDW.
R
Radioactive Waste Disposal Well.
X
Other Class I Wells (not included in Type “I,” “M,” “H,” or “R”).
CLASS II: Wells used to dispose of fluids which are brought to the surface in connection with oil or natural gas
production; to inject fluids for enhanced recovery of oil or natural gas; or to store hydrocarbons.
Type
A
Annular Disposal Well.
D
Produced Fluid Disposal Well.
H
Hydrocarbon Storage Well (excluding natural gas).
R
Enhanced Recovery Well.
Other Class II Wells (not included in Type “A,” “D,” “H,” or “R”).
X
CLASS III: Wells that inject fluids for the extraction of minerals.
Type
G
In Situ Gasification Well.
Solution Mining Well.
M
Sulfur Mining Well by Frasch Process.
S
Geothermal Well.
T
Uranium Mining Well (excluding solution mining of conventional mines).
U
Other Class III Wells (not included in Type “G,” “M,” “S,” “T,” “U,” or “X”).
X
CLASS IV: Wells that inject hazardous waste into/above USDWs.
Type
H
Hazardous Facility Injection Well.
R
Remediation Well at RCRA or CERCLA site.
CLASS V: Wells not currently classified as Class I, II, III, IV, or VI.
Type
Industrial Well.
A
Beneficial Use Well.
B
Fluid Return Well.
C
Sewage Treatment Effluent Well.
D
Cesspool (non-domestic).
E
Septic System.
F
Experimental Technology Well.
G
Drainage Well.
H
Mine Backfill Well.
I
Waste Discharge Well.
J

This page is intentionally blank. 

Approval Expires xx/xx/xxxx OMB No. 2040-0214

Type or print all information. See reverse for instructions
United States Environmental Protection Agency

Class V Well Pre-Closure Notification Form
2. Description of Facility/Wells To Be Closed

1. Name and Address of Facility

3. State

4. County

5. Permit (or EPA ID) Number

6. Latitude

Longitude

7. Name, Address, Phone Number and/or Email of Permittee

8. Name, Address, Phone Number and/or Email of Legal Contact

9. Type of Wells

10. Number of Well(s)

12. Type of discharge:

11. Well construction type (check all that apply):
Drywell

Septic tank

Cesspool

Improved sinkhole

Drainfield/Leachfield

Other

13. Average flow (gallons/day)

14. Year(s) of well(s) construction

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

Clean out well

Appropriate disposal of remaining fluids/sediments

Install permanent plug

Remove well & any contaminated soil

Conversion to other well type

Other (describe):

(Describe):

16. Proposed date of well closure

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

EPA Form 7520-17

Signature

Date Signed

INSTRUCTIONS FOR 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, HI, IA, IN, KY, MI, MN, MT, NY, PA, SD, VA, VI, and on 
all Tribal Lands. If you are located in another 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. 
Please read: The purpose of this form is to serve as a notification to the UIC Director by a Class V well owner or operator 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 or 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. 
1. NAME AND ADDRESS OF FACILITY: Supply the name and street address of the facility where the well is located. Include the city/town, State, and 
ZIP Code. If there is no street address for the Class V well, provide the route number or locate the well on a map and attach it to this form.  
2. DESCRIPTION OF FACILITY/WELL TO BE CLOSED: Describe the well (or, in a multiple‐well facility, which wells) to be closed. Attach schematics or 
drawings, if necessary to fully describe the facility. 
Enter the 3. STATE and 4. COUNTY where the well is located. For States that do not have counties, use the name of that State’s equivalent 
jurisdiction at a more local level.  
5. PERMIT (OR EPA ID) NUMBER: Enter the well identification number or permit number assigned to the injection well by the EPA or the permitting 
authority. 
6. LATITUDE AND LONGITUDE: Enter the latitude and longitude of the well in decimal degrees, to five or six places if possible. 
7. NAME, ADDRESS, PHONE NUMBER AND/OR EMAIL OF PERMITTEE: 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). 
8. NAME, ADDRESS, PHONE NUMBER AND/OR EMAIL OF LEGAL CONTACT: Provide the name and phone number of the legal contact for any 
questions regarding the information provided on this form. If the legal contact is the same as the permittee, enter “same as permittee.” 
9. TYPE OF WELL: Indicate the type of Class V well that you intend to close (for example, motor vehicle waste disposal well or cesspool). 
10. NUMBER OF WELLS: Provide the number of wells of this well type at your location that will be closed. 
11. WELL CONSTRUCTION TYPE: Check the appropriate box(es) to indicate the type of well construction. Check all that apply to your situation. For 
example, for a septic tank that drains into a drywell, check both the "septic tank" and "drywell" boxes. Please provide a generalized sketch or 
schematic of the well construction, if one is available. 
12. TYPE OF DISCHARGE: 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. 
13. AVERAGE FLOW: Estimate the average daily flow into the well, in gallons per day. 
14. YEAR OF WELL CONSTRUCTION: 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. 
15. TYPE OF WELL CLOSURE: Check the appropriate box(s) to indicate briefly how the well closure is expected to proceed. Check all that apply to 
your situation. For example, check “Install permanent plug” and “Conversion to other well type” if the connection of an automotive service bay 
drain leading to a septic tank and drainfield will be closed (and a cement plug placed in the service bay drain and the pipe leading to the washroom 
connection), but the septic system will continue to be used for washroom waste disposal only. In this example, the motor vehicle waste disposal 
well is being converted to another well type (a large capacity septic system). 
16. PROPOSED DATE OF WELL CLOSURE: Provide the date on which closure of the well is planned.  
CERTIFICATION: This form must be signed and dated by either: a responsible corporate officer for a corporation, by a general partner for a 
partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected official for a public agency.  
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden or this collection of information is estimated to average 1.4 
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. 

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency

COMPLETION REPORT FOR INJECTION WELLS
Name, Address, Phone Number and/or Email of Permittee

County

State

Permit (or EPA ID) Number

API Number

Full Well Name

Locate well in two directions from nearest lines of quarter section and drilling unit

Latitude

Surface Location
1/4 of

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Longitude

Range

Injection Interval (Perforated/Open Hole Interval)

Anticipated Daily Injection Volume (Bbls)
Average

Maximum

Feet

to Feet

Depth to Bottom of Lowermost USDW (Feet)
Name of Injection Zone

Date Drilling Began

Fracture Pressure of Injection Zone
Date Drilling Completed
Permeability of Injection Zone
Date Well Completed

Porosity of Injection Zone

Complete Attachments; See Instructions.

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 7520-18 (Rev. 12-11)

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520-18
This form must be completed for each injection well. This form is appropriate for all injection well classes, and replaces the
previous Form 7520-9 and Form 7520-10. While reports or other information developed by contractors or service companies
may be attached, this form must be signed by a responsible entity as described at 40 CFR 144.32.
NAME, ADDRESS, PHONE AND/OR EMAIL OF PERMITTEE: Enter the name and street address, city/town, state, and ZIP
code of the permittee. Also provide an email address (if available) and/or a phone number.
Enter the STATE and COUNTY where the well is located. For States that do not have counties, use the name of that State’s
equivalent jurisdiction at a more local level.
PERMIT OR EPA ID NUMBER: Enter the well identification number or permit number assigned to the injection well by the
EPA or the permitting authority.
API NUMBER: Enter the number assigned by the local jurisdiction (usually a State Oil and Gas Agency) using the American
Petroleum Institute standard numbering system.
FULL WELL NAME: Enter the full name of the well or project.
WELL LOCATION: Fill in the complete township, range, and section to the nearest quarter-quarter section. A township is
north or south of the baseline, and a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the
distance, in feet, from the nearest north or south line and nearest east or west line of the quarter-section. Also, enter the
latitude and longitude of the well in decimal degrees, to five or six places if possible; be sure to include a negative sign for
the longitude of a well in the Western Hemisphere and a negative sign for the latitude of a well in the Southern Hemisphere.
ANTICIPATED DAILY INJECTION VOLUME: Enter the anticipated average and maximum daily volume of fluid to be
injected, in barrels.
INJECTION INTERVAL: Enter the depths, in feet, to the top and bottom of the perforated hole/open interval of the well
through which injected fluids will exit the well. (Note: this is different from the depth of the injection zone.) Provide information
about how these were derived, e.g., by attaching a step-rate test or other test results. (See the description of attachments
below.)
Enter the DEPTH TO BOTTOM OF THE LOWERMOST USDW (i.e., formation containing less than 10,000 mg/L total
dissolved solids), in feet.
Enter the DATE DRILLING BEGAN, the DATE DRILLING WAS COMPLETED, and the DATE THE WELL WAS
COMPLETED in the appropriate blanks.
Enter information about the permitted injection formation, including the NAME OF THE INJECTION ZONE, the calculated
FRACTURE PRESSURE, and the PERMEABILITY and POROSITY of the injection zone in the appropriate blanks.
CERTIFICATION: This form must be signed and dated by either: a responsible corporate officer for a corporation, by a
general partner for a partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected
official for a public agency.
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information
is estimated to average between 3.3 and 3.9 hours per response, depending on the injection well class. 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.

INSTRUCTIONS FOR COMPLETING ATTACHMENTS TO FORM 7520-18
Please attach the following information to the completion report. Reports prepared by contractors or service companies may
be submitted, provided they are clear and legible and the requested information is accessible. Please be sure to specify units
as needed, e.g., of depth, pressure, temperature, etc.
I. Geologic Information
1. Provide a geologic description of the rock units penetrated by name, age, depth, thickness, and lithology of each rock unit
penetrated.
2. Provide information about the injection formation that supports the information provided on the form, for example: (1)
name; (2) depth (drilled); (3) thickness; (4) formation fluid pressure; (5) age of unit; (6) bottom hole temperature; (7) lithology;
and (8) bottom hole pressure.
3. Provide chemical characteristics of formation fluid, including a chemical analysis.
4. Provide a description of all USDWs, including: (1) depth below ground surface to base of fresh water (less than 10,000
mg/L TDS); and (2) a geologic description of aquifer units with name, age, depth, thickness, lithology, and average total
dissolved solids.
II. Well Design and Construction
1. Provide information on the surface, intermediate, and long string casing and tubing. Describe: the materials used; outside
diameter size; weight/foot, grade, and whether new or used; and the depth to which each casing string is set (include
appropriate units, e.g., below ground surface, below Kelly bushing, etc.).
2. Provide data on the holes drilled for each casing string, including the bit diameter and depth of hole.
3. Provide data on the well cement for each casing string, such as type/class, additives, amount, method of emplacement,
and depth to top of cement.
4. Describe the packer (if used) such as type, name and model, setting depth, and type of annular fluid used.
5. Provide data on centralizers, including number, type, and depth.
6. Provide data on bottom hole completions, including the depth and diameter of the hole.
III. Monitoring Systems. Describe the recording and nonrecording injection pressure gauges, casing-tubing annulus
pressure gauges, injection rate meters, temperature meters, and other meters or gauges. Also provide information on
constructed monitoring wells such as location, depth, casing diameter, method of cementing, etc.
IV. Logging and Testing Results. Provide a report describing the types of geophysical logs, cores, and other tests
performed; date of the logs; the intervals logged; and interpretation of the results. Include a description and the results of
deviation checks run during drilling. If requested, provide a final print of all geophysical logs run.
V. As-built Schematic. Provide a diagrammatic sketch of the surface and subsurface construction details of the injection
well as-built, showing casing, cement, tubing, packer, etc., with proper setting depths. The sketch should include the well
head and gauges.
VI. Mechanical Integrity Testing. Provide data demonstrating mechanical integrity pursuant to 40 CFR 146.08. Describe
the method and results of mechanical integrity testing.
VII. Report on the compatibility of injected wastes with fluids and minerals in both the injection zone and the confining
zone.
VIII. Report the status of corrective action on deficient wells in the area of review.
IX. Include the anticipated maximum pressure and flow rate at which injection will operate.
X. Stimulation. Describe any stimulation performed, including the interval treated and the materials and amounts used.

This page is intentionally blank. 

OMB No. 2040-0042

Approval Expires 11/30/2014

United States Environmental Protection Agency

WELL REWORK RECORD, PLUGGING AND ABANDONMENT PLAN,
OR PLUGGING AND ABANDONMENT AFFIDAVIT

Name and Address, Phone Number and/or Email of Permittee

Permit or EPA ID Number

API Number

Full Well Name

State

County

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface Location
1/4 of

Well Class
Class I
Class II
Class III
Class V

1/4 of Section

Township

ft. from (N/S)

Line of quarter section

ft. from (E/W)

Line of quarter section.

Range

Timing of Action (pick one)

Latitude
Longitude

Type of Action (pick one)

Notice Prior to Work

Well Rework

Date Expected to Commence
Plugging and Abandonment
Report After Work

Conversion to a Non-Injection Well

Date Work Ended

Provide a narrative description of the work planned to be performed, or that was performed. Use additional pages as necessary. See instructions.

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 7520-19 (Rev. 12-11)

Signature

Date Signed

INSTRUCTIONS FOR FORM 7520‐19 
This form replaces forms 7520‐12 and 7520‐14. Use this form only when work is planned or has occurred that affects the well’s construction or 
operation as an injection well, including work on the casing, tubing or packer (or for shallow Class V wells, the subsurface fluid emplacement 
network). Use one form per injection well. While reports or other information developed by contractors or service companies may be attached, this 
form must be signed by a responsible entity as described at 40 CFR 144.32. Note: operators closing Class V wells should use Form 7520‐17.  
NAME, ADDRESS, PHONE AND/OR EMAIL OF PERMITTEE: Enter the name and street address, city/town, state, and ZIP code of the permittee. Also 
provide an email address (if available) and/or a phone number. 
PERMIT OR EPA ID NUMBER: Enter the well identification number or permit number assigned to the well by the EPA or the permitting authority. 
API NUMBER: Enter the number assigned by the local jurisdiction (usually a State Oil and Gas Agency) using the American Petroleum Institute 
standard numbering system.  
FULL WELL NAME: Enter the full name of the well or project. 
Enter the STATE and COUNTY where the well is located. For States that do not have counties, use the name of that State’s equivalent jurisdiction at 
a more local level. 
WELL LOCATION: Fill in the complete township, range, and section to the nearest quarter‐quarter section. A township is north or south of the 
baseline, and a range is east or west of the principal meridian (e.g., T12N, R34W). Also include the distance, in feet, from the nearest north or south 
line and nearest east or west line of the quarter‐section. Also, enter the latitude and longitude of the well in decimal degrees, to five or six places if 
possible; be sure to include a negative sign for the longitude of a well in the Western Hemisphere and a negative sign for the latitude of a well in 
the Southern Hemisphere.  
Enter the WELL CLASS, i.e., the class of injection well as defined in 40 CFR 144.6. 
TIMING OF THE ACTION: Check Notice prior to work if the activity has not yet occurred (i.e., is planned). Check Report after work if the activity 
described has already occurred. As appropriate, include the date the activity is expected to start or the date the activity was completed. (Note this 
may not be available, e.g., for a plugging plan submitted with a permit application.) 
TYPE OF ACTION: Check the appropriate box to describe the kind of activity being reported. Check Well Rework for work that was/will be 
performed on the well after it has already been in operation as an injection well. Check Plugging and Abandonment to report on plans for or 
descriptions of final closure/plugging after use as an injection well. Check Conversion to a Non‐Injection Well if the well is to be converted to 
something other than an injection well. 
Provide a NARRATIVE DESCRIPTION of the work planned to be performed, or that was performed. The narrative should include a description of the 
main procedures planned or that occurred during the work activity. A service company report, daily report, or similar document may be attached if 
it includes all the requested information and is clear and legible. 
For well reworks, include the following information: The reason for the well rework; depths of activity; type of activity; changes to injection well 
configuration, well casing, or cement behind casing; any plug added to the well and its depth; any newly drilled interval and its depth; method(s) to 
demonstrate that the well has mechanical integrity (as applicable); and any deviations from the approved rework plan (as applicable). 
For a well plugging plan, include the following information: Reason for the well plugging; number of plugs placed, and their depths; materials 
used as plugs (e.g., cast iron bridge plug, cement, cement retainer); method to set plugs; and wait‐on‐cement times, if any. Also provide one or 
more cost estimates from an independent firm in the business of plugging and abandoning wells to plug the well as described in the plan. 
For well plugging affidavit, include the following information: Reason for the well plugging; number of plugs placed, and their depths; materials 
used as plugs (e.g., cast iron bridge plug, cement, cement retainer); method to set plugs; wait‐on‐cement times, if any; and any deviations from the 
approved plugging plan (if applicable). 
For conversion to a non‐injection well, include the following information: Depths of activity; type of activity; changes to injection well 
configuration, well casing, or cement behind casing; any plug added to the well and its depth; any newly drilled interval and its depth; depths of 
new perforations; and method(s) to demonstrate that the well has mechanical integrity (as applicable). 
For all of the above activities, include a well sketch depicting the work, results of well tests/logging performed, service company tickets, and any 
other available information demonstrating how the work was/is to be performed. Also, specify whether depths are below ground surface, relative 
to Kelly bushing, etc.  
CERTIFICATION: This form must be signed and dated by either: a responsible corporate officer for a corporation, by a general partner for a 
partnership, by the proprietor of a sole proprietorship, or by a principal executive or ranking elected official for a public agency. 
PAPERWORK REDUCTION ACT NOTICE: The public reporting and recordkeeping burden for this collection of information is estimated to average 
between 6.0 and 7.9 hours per response, depending on the injection well class. 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.