7520-11 Annual Disposal/Injection Well Monitoring Report

OMB No. 2040-0042

Approval Expires 12/31/2018

United States Environmental Protection Agency
Washington, DC 20460

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

Name and Address of Surface Owner

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

N

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

Section ____ Township ____ Range ____

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface
Location ____ ft. frm (N/S) ____ Line of quarter section
and ____ ft. from (E/W) ____ Line of quarter section.
W

E

WELL ACTIVITY
Brine Disposal
Enhanced Recovery
Hydrocarbon Storage

TYPE OF PERMIT
Individual
Area
Number of Wells ____

Lease Name

Well Number

S

INJECTION PRESSURE
MONTH

YEAR

AVERAGE PSIG

TOTAL VOLUME INJECTED

MAXIMUM PSIG

BBL

MCF

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

MAXIMUM PSIG

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

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

Signature

Date Signed

PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is estimated to average 30 hours per quarter.
Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or provide
information to or for a Federal Agency. This includes the time needed to review instructions; develop, acquire, install, and utilize
technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining
information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable
instructions and requirements; train personnel to be able to respond to the collection of information; search data sources; complete
and review the collection of information; and, transmit or otherwise disclose the information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods
for minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division,
U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number
in any correspondence. Do not send the completed forms to this address.

EPA Form 7520-11 Reverse