Form 7520-6 UIC Permit Application

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

Approval Expires 12/31/2018

I. EPA ID Number

Underground Injection Control

T/A

Permit Application

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

U

Read Attached Instructions Before Starting

For Official Use Only
Application approved
mo

day

Date received

year

mo

day

Permit Number

year

Well ID

II. Owner Name and Address

FINDS Number

III. Operator Name and Address

Owner Name

Owner Name

Street Address
City

State

IV. Commercial Facility

Phone Number

Street Address

ZIP CODE

City

V. Ownership

Phone Number
State

VI. Legal Contact

Yes

Private

Owner

No

Federal

Operator

ZIP CODE

VII. SIC Codes

Other
VIII. Well Status
Date Started

A.

mo

day

(Mark "x")

B. Modification/Conversion

year

C. Proposed

Operating
IX. Type of Permit Requested
A. Individual

(Mark "x" and specify if required)

Number of Existing Wells

B. Area

Number of Proposed Wells

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

B. Type(s)

(enter code(s))

(enter code(s))

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

(see reverse)

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

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

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

Min

Longitude
Sec

Deg

Min

XII. Indian Lands (Mark 'x')

Township and Range
Sec

Sec

Twp

Range

1/4 Sec

Feet From

Line

Feet From

Line

Yes
No

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

Attach maps where

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

(Type or Print)

C. Signature

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

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

C

Well Class and Type Codes
Class I

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

Type “I”
“M”
“W”
“X”

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

Class II

Oil and gas production and storage related injection wells.

Type “D”
“R”
“H”
“X”

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

Class III

Special process injection wells.

Type “G”
“S”
“U”
“X”

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

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

Attachments to Permit Application
Class

Attachments

I new well
existing

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

II new well
existing

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

III new well
existing

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

Other Classes

EPA Form 7520-6 (12-11)

To be specified by the permitting authority

page 2 of 6

INSTRUCTIONS - Underground Injection Control (UIC) Permit Application
Paperwork Reduction Act: The public reporting and record keeping burden for this collection of information is estimatedto average
224 hours for a Class I hazardous well application, 110 hours for a Class I non-hazardous well application,67 hours for a Class II well
application, and 132 hours for a Class III well application. Burden means the total time, effort, or financial resource expended by
persons to generate, maintain, retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to
review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting,validating,and verifying
information, processing and maintaining information, and disclosing andproviding information; adjust the existing ways to comply with
any previously applicable instructions and requirements;train personnel to be able to respond to the collection of information; search
data sources; complete and review the collection of information; and, transmit or otherwise disclosethe information. An agency may
not conduct or sponsor, and a person is not required to respond to, a collectionof information unless it displays a currently valid OMB
control number. Send comments on the Agency’s need for this information, the accuracyof the provided burden estimates, and any
suggested methods for minimizing respondent burden, including the use of automated collection techniques to Director, Collection
Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, DC 20460. Include the
OMB control number in any correspondence. Do not send the completed forms to this address.
This form must be completed by all owners or operators of Class I, II, and III injection wells and others who may be directed to
apply for permit by the Director.
I.

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

II.

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

III.

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

IV.

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

V.

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

VI.

LEGAL CONTACT - Mark the appropriate box.

VII.

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

VIII.

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

IX.

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

X.

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

XI.

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

XII.

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

XIII.

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

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

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

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

B.

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

C.

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

D.

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

EPA Form 7520-6

Page 4 of 6

E.

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

F.

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

G.

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

H.

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

I.

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

J.

STIMULATION PROGRAM - Outline any proposed stimulation program.

K.

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

L.

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

M.

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

N.

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

O.

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

P.

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

Q.

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

EPA Form 7520-6

Page 5 of 6

R.

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

S.

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

T.

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

U.

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

EPA Form 7520-6

Page 6 of 6