# APPENDIX E

## APPENDIX E Underground Injection Control Program Reporting Forms

Number Form 7520-1 Permit Review and Issuance/Wells in Area of Review 7520-2A Compliance Evaluation 7520-2B Compliance Evaluation - Significant Noncompliance 7520-3 Mechanical Integrity Test/Remedial Actions 7520-4 Quarterly Exceptions List 7520-6 UIC Permit Application 7520-7 Application to Transfer Permit 7520-8 Injection Well Monitoring report 7520-9 Completion Form for Injection Wells 7520-10 Completion Report for Brine Dispos al, Hydrocarbon Storage, or Enhanced Recovery Well 7520-11 Annual Disposal/Injection Well Monitoring Report 7520-12 Well Rework Record 7520-14 Plugging and Abandonment Plan 7520-16 Inventory of Injection Wells 7520-17 Pre-Closure Notification FormPlease type or print all information. Please read instructions
. OMB No. 2040-0042 Form Expires 11/30/2014 United States Environmental Protection Agency

Office of Grou n d Wate r an d Drinking Water Washington, DC 20460

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

### UIC Federal Reporting System 

## Part I: Permit Review and Issuance/ Wells in Area of Review I. Name and Address of Reporting Agency United States Environmental Protection Agency

II. Date Prepared (month, day, year) III. State Contact (name, telephone no.) IV. Reporting Period (month, year) From 

## October 1, 20 To

Item Class and Type of Injection Wells

I II III IV V SWD 2D ER 2R HC 2H V. Permit Application Number of Permit Applications Received

VI. PermitDetermination Permit

Issued A Number of Individual Permits Issued (One Well) New Wells Existing Wells

B Number of area Permits* Issued (Multiple Wells) (*See instructions on back) New Well Field Existing Well Field

C Number of Wells in Area Permits (See B above) New Wells Existing Wells Permit Not Issued D Number of Permits Denied/Withdrawn (after complete technical review) Modification

Issued E Number of Major Permit Modifications Approved VII. Permit

File Review Number of Rule-Authorized Class II Wells Reviewed Wells Reviewed Wells Deficient

VIII. Area

of Review (AOR) Wells Reviewed A Number of Wells in Area of Review Abandoned Wells Other Wells Wells Identified

for C/A B Number of Wells Identified for Corrective Action Abandoned Wells Other Wells

Wells with C/A C 1. Number of Wells in AOR with Casing Repaired/Recemented 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)

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. Certification

Signature and Typed or Printed Name and Title of Person Completing Form Date Telephone No.

EPA Form 7520-1 (Rev. 12-11) Previous edition is obsolete.

# Instructions and Definitions All reporting is cumulative over the federal fiscal year, and includes activities from Oc tober 1- September 30. Please do not leave anything blank on this form. Enter a 0 if there are no wells that apply to the information requested; enter “NA” if the information does not apply to your program (e.g., if you do not oversee that class of well). Section V. Permit Application Enter, under each well class, the total number of permit applications that have been received this year to date. Include all applications regardless of their status for “New” and “Existing” wells. A “New Well” is any well that began operation after the effective date of the State (or EPA) Underground Injection Control Program. An “Existing Well” is any injection well that was in existence on the effective date of the State (or EPA) UIC Program. Section VI. Permit Determination Permit Determinations include th e approval or denial of UIC permit requests/actions such as: applications fo r 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 revi ew before issuance, and a final decision document signed by the regulating authority. Item A: For each well class, ente r the number of individual permits issued for “New” or “Exis ting” wells this federal fiscal year to date. Item B: For each well class, enter th e number of area permits that have been issued for “New” or “Existing” well fields this year to date. (“New” in this case, desc ribes a nonhazardous injection well field having only new wells or a mixture of new and existing wells. “Existing” describes a nonhazardous well field that has existing wells only.) Item C: For each well class, ente r 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 federa l fiscal year to date. The denial of a permit or major modificatio n 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 comple te technical review, public notification or review, and a final decision document signed by the regulating authority. Section VII. Permit File Review A complete technical review of an existing (rule authorized) Class II well record may be conducted to determine whether the well is in compliance with UIC regulatory requirements in lieu of a permit determination. The well record (or file) review may include an evaluation of siting reports, wells in the area of review, construction, operating, monitori ng or other reports. Existing Class II wells should be routinely reviewed at least once every five years during the life of the well. Wells Reviewed: For rule authorized (existing) Class II wells only, enter the number of wells with permit files reviewed and compliance status determined this federal fiscal year to date. Wells Deficient: For rule authorized Class II wells, enter the number of reviewed wells that were found deficient (not in compliance with UI C regulations). Section VIII. Area of Review (AoR) 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. Item A: For each well class, ente r 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. “Abandoned” includes any well penetr ating the injection zone in the AoR that has been properly or improperly plugged and/or abandoned. “Other” includes any producing we ll, operable injection well, dry hole, exploratory well, etc., that penetrates the injection zone in the AoR. Corrective Action is required for those wells that penetrate the injection zone in the AoR that are improperly sealed, completed, or abandoned. Item B: For each well class, enter the number of “Abandoned” and “Other” wells in the AoR that have required corrective action for each permit application or file reviewed this federal fiscal year to date. Item C: For each well class, enter the number of wells in the AoR which have received corrective action (be specific) for all permit applications or files that have b een reviewed this year to date. Paperwork Reduction Act Notice The public reporting and record k eeping burden for this collection of information is estim ated to average 4.5 hours per year. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, re tain, 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 fo r the purposes of collecting, validating, and verifying informa tion, processing and maintaining information, and disclosing and pr oviding 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 info rmation; 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 Av e., NW., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.
EPA Form 7520-1 (11-14) RevisedPlease type or print all information. Please read instructions on rever se. OMB No. 2040-0042 Approval Expires 1 1/30/2014 United States Environmental Protection Agenc y Washington, DC 20460

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

### UIC Federal Reporting System 

## Part II: Compliance Evaluation Offic e of G round Water and Drinking Water I. Name and Address of Reporting Agency United States Environmental Protection Agency

II. Date Prepared (month, day, year) III. State Contact (name, telephone no.) IV. Reporting Period (month, year) From 

## October 1, 20 To

Item Class and Type of Injection Wells

I II III IV V SWD 2D ER 2R HC 2H

V. Summary
of
Violations Total Wells A Number of Wells with Violations

Total Violations B 1. Number of Unauthorized Injection Violations 2. Number of Mechanical Integrity Violations
3. Number of Operation and Maintenance Violations 4. Number of Plugging and Abandonment Violations 5. Number of Monitoring and Reporting Violations (Specify) 6. Number of Other Violations

VI. Summary
of
Enforcement Total Wells A Number of Wells with Enforcement Actions

Total Enforcement

Actions B 1. Number of Notices of Violation
2. Number of Consent Agreements
3. Number of Administrative Orders
4. Number of Civil Referrals
5. Number of Criminal Referrals
6. Number of Well Shut-ins
7. Number of Pipeline Severances
8. Number of Other Enforcement Actions (Specify) VII. Summary of Compliance Number of Wells Returned to Compliance A. This Quarter
B. This Year VIII. Contamination Number of Cases of Alleged Contamination of a USDW IX. MIT Resolved Percent of MIT Violations Resolved in 90 Days X. Remarks/Ad Hoc Report (Attach additional sheets)
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. Certification

Signature and Typed or Printed Name and Title of Person Completing Form Date Telephone No.

EPA Form 7520-2A (12-11) Replaces EPA Form 7520-2 which is obsolete

## Definitions and Instructions All reporting is cumulative over the federal fiscal year, and includes activities from October 1- March 31 (for midyear reporting) and from October 1- September 30 (for end of year reporting). Please do not leave anything blank on this form. Enter a 0 if there are no wells that apply to the information requested; enter “NA” if the information does not apply to yo ur program (e.g., if you do not oversee that class of well). A Class I, II, III, IV, or V injection well with a violation of a permit or rule requirement is said to be in noncompliance. Note: A well with certain types of violations may also be in significant noncompliance. (See Form 7520-2B (Reverse) for definitions of SNC violations.) Section V. Summary of Violations (Includes all noncompliance, significant and non-significant) A. Total Wells: For each well class, enter the number of wells with one or more violations in this fede ral fiscal year to date. Enter each well only once. Include all wells w ith 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 th is federal fiscal year to date. Section VI. Summary of Enforcement A. Total Wells: For each well class, enter the number of wells with violations that have been addr essed by the specific type of enforcement action indicated in the row, in this federal fiscal year to date. Enter each well only once. B. Total Enforcement Actions: Items 1-8: For each well class, enter the number of times wells with violations been addressed by the specific type of enforcement action indicated in the row, in this federal fiscal year to date. (Count draft and final Administrative Orders together.) Section VII. Number of Wells Returned to Compliance A “Well Returned to Compliance” is a well that has all underlying violations resolved and compliance has been verified by the primacy program. Note: An enforcement acti on alone (e.g., well shut-in) does not constitute a “return to compliance;” however, plugging and abandonment does c onstitute a return to compliance. A. For each well class, enter the number of wells returned to compliance in the current quarter only. B. For each well class, enter the number of wells returned to compliance this federal fiscal year to date. Enter each well only once. Section VIII. USDW Contaminations For each well class, enter the number of times a well in noncompliance has allegedly contaminated an u nderground source of drinking water (USDW) this federal fi scal 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 c ounted 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 vi olations that occurred within the year prior to the reporting cutoff.
 Add up the number of these violations that were resolved within 90 days as of 3/31(for midyear reporting) or as of 9/30 (for end of year reporting).
 Calculate the percentage of total MIT violations that were resolved in 90 days or less. Example for Midyear reporting:
 Number of violations that occurred from 7/1 – 3/31 = 8
 Number of these violations resolved within 90 days as of 3/31 = 2
 Percentage of MIT violation resolved within 90 days = 25% Example for End of Year reporting:
 Number of MIT violations that occurred from 7/1 – 6/30 = 10 o 8 from midyear plus 2 additional (4/1 to 6/30)

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

 Percentage of MIT resolved within 90 days by 9/30 = 50% Paperwork Reduction Act The public reporting and record keeping burden for this collection of information is estimated to aver age 6 hours per response. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, re tain, or disclose or provide information to or for a Federal Agency. This includes the time needed to review instructions; deve lop, acquire, install, and utilize technology and systems for the pur poses of collectin g, validating, and verifying information, proce ssing and maintaining information, and disclosing and providing inform ation; 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 c onduct or sponsor, and a person is not required to respond to, a coll ection 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 sugge sted methods for minimizing respondent burden, including th e use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Incl ude the OMB control number in any correspondence. Do not send the completed forms to this address. EPA Form 7520-2A (11-14) RevisedPlease type or print all information. Please read instructions on reverse. OMB No. 2040-0042 Ap p roval Expires 1 1/30/2014 United States Environmental Protection Agency Washington, DC 20460

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

### UIC Federal Reporting System 

## Part II: Compliance Evaluation

Significant Noncompliance

O ffic e of Ground Water and Drinking Water I. Name and Address of Reporting Agency United States Environmental Protection Agency

II. Date Prepared (month, day, year) III. State Contact (name, telephone no.) IV. Reporting Perio d (month, year) From 

## October 1, 20 To

Item Class and Type of Injection Wells

I II III IV V SWD 2D ER 2R HC 2H

V. Summary of SignificantNonCompliance

(SNC) Total Wells A Number of Wells with SNC Violations

Total 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 (Specify) Number of Other SNC Violations 7.

VI. Summary
of
Enforcement

Against

SNC Total Wells A Number of Wells with Enforcement Actions Against SNC

Total Enforcement

Actions B 1. Number of Notices of Violation 2. Number of Consent Agreements/Orders 3. Number of Administrative Orders 4. Number of Civil Referrals 5. Number of Criminal Referrals 6. Number of Well Shut-ins 7. Number of Pipeline Severances 8. Number of Other Enforcement Actions (Specify) Against SNC Violations VII. Summary of Compliance Number of Wells in SNC Returned to Compliance A. This Quarter
B. This Year VIII. Contamination Number of Cases of Alleged Contamination of a USDW

IX. Well Closure Class IV/Endangering Class V Well Closures Involuntary Well Closure Voluntary Well Closure

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. Certification

Signature and Typed or Printed Name and Title of Person Completing For m Date Telephone No.

EPA Form 7520-2B (12 -11) Replaces EPA Form 7520 -2 which is o b solete
.

### Instructions and Definitions Section IV. Reporting Period: All reporting is cumulative over the federal fiscal year, and includes activ ities from October 1- March 31 (for midyear reporting) and from October 1- September 30 (for end of year reporting). Please do not leave anything blank on this form. Enter a 0 if there are no wells that apply to the information requested; enter “NA” if the information does not apply to your program (e.g., if you do not oversee that class of well). Note: Significant Noncompliance violations are a subset of the violations reported on EPA Form 7520-2A. Definitions of SNC Violations: SNC violations are violations that endanger or pose a significant potent ial to endanger underground sources of drinking water (USDWs), and violat ions that are not addressed after enforcement actions. For example: 1. The following violati ons for a Class I well:

a. Contamination of a USDW; b. Injection of unauthorized fluid(s); c. Injection into unauthorized zones; d. Failure to cease injection after loss of MI detected; Failure to comply with corrective action requirements; e. Failure to operate auto matic shutdown system; f. Failure to operate automatic warning system; g. Unauthorized plugging and abandonment; h. Violation of a Formal Order; i. Knowing submission of false information; j. Violations involving loss of mechanical integrity; k. Violations of maximu m injection pressure; l. Failure to install and/or operat e injection pressure and annulus pressure monitoring systems or othe r monitoring systems, required by permit or rule; and m. Failure to maintain required annulus pressure. Also, any Class I well with a non-SNC violation that is noted three times within twelve months of the first viol ation is considered to be in SNC. 2. The following violations fo r a Class II, III, or V well:

a. Unauthorized Injection – Any unau thorized emplacement of fluids (where formal authorization is required); b. Mechanical Integrity – Well operation without mechanical integrity which causes the movement of fluid outside the authorized zone – if injection of such fluid may have the potential for endangering a USDW; c. Injection Pressure – Well operation at an injection pressure that exceeds the permitted or authorized injection pressure and causes the movement of fluid outside the authorized zone of injection – if such movement may have the po tential for endangering a USDW; d. Plugging and Abandonment – The plugging and abandonment of an injection well in an unauthorized manner. These wells are in SNC only when there is endangerment of USDW and there is an identifiable owner/operator; e. Violation of a Formal Order – Any violation of a formal enforcement action, including an administrative or judicial order, consent agreement, judgment, or equivalent action; or f. Falsification – The knowing subm ission or use of any false information in a permit application, periodic report or special request for information about a well. 3. Any violation for a Class IV well. EPA Form 7520-2B (11-14) Revised Section V. Total No. of We lls with SNC Violations: Significant Noncompliance violations are a subset of the vi olations reported on EPA From 7520-2A. For each well class, enter the number wells with SNC violations identified in the federal fis cal 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 s ubset of the violations reported on EPA Form 7520-2A. For each well class, enter the number of wells with SNC violations that have received an enforcement action(s) this year to date. Report the well even if the violation has been corrected. Count each well only once. For each well class in subsections 1 through 7, enter the number of times wells with SNC violations have received each type enforcement action this federal fiscal year to date. Section VII. No. of Wells Returned to Compliance: “Well Returned to Compliance” is a well that has all underlying violations resolved and compliance has been verified by the primacy program. Note: an enforcement action alone (e .g., well shut-in) does not constitute a “return to compliance;” however, plugging and abandonment does constitute a return to compliance. For each well class in subsection A, enter the number of wells returned to compliance (as a result of an enforcement action against a SNC violation). For each well class in subsection B, enter the number of wells returned to compliance (as a result of an enforcement action against an SNC violation) this federal fiscal year to date. Enter each well only once. Section VIII. USDW Contaminations: For each well class, enter the number of times a well in SNC has al legedly 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 clos ed as a direct result of outreach activities. Involuntary well closure means wells cl osed as a result of enforcement actions or permit call-ins. Well closure describes a process to pe rmanently discontinue injection in accordance with the UIC regulations. Paperwork Reduction Act The public reporting and record keeping burden for this collection of information is estimated to average 5.5 hours per response. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to the collection of information; search data sources; complete and review the collection of information; and, transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, DC 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.Please type or print all information. Please read instructions on reverse
. OMB No. 2040-0042 Approval Expires 1 1/30/2014 United States Environmental Protection Agency Washington, DC 20460

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

### UIC Federal Reporting System 

## Part III: Inspections Mechanical Integrity Testing

Office of Ground Water and Drinking Water I. Name and Address of Reporting Agency United States Environmental Protection Agency

II. Date Prepared (month, day, year) III. State Contact (name, telephone no.) IV. Reporting Period (month, year) From 

## October 1, 20 To

Ite m Class and Type of Injection Wells

I II III IV V SWD 2D ER 2R HC 2H

V. Summary of Inspections Total Wells A Number of Wells Inspected

Total Inspections B 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

VI. Summary

of

Mechanical

Integrity

(MI) Total Wells A Number of Wells Tested or Evaluated for Mechanical Integrity (MI) B No. of Rule-Authorized Wells Tested/Evaluated for MI Passed 2-part test Failed 2-part test

For Significant

Leak C 1. Number of Annulus Pressure Monitoring Record Evaluations Well Passed Well Failed 2. No. of Casing/ Tubing Pressure Tests Well Passed Well Failed 3. Number of Monitoring Record Evaluations Well Passed Well Failed 4. (Specify) No. of Other Significant Leak Tests/Evaluations Well Passed Well Failed

For Fluid Migration D 1. Number of Cement Record Evaluations Well Passed Well Failed 2. Number of Temperature/ Noise Log Tests Well Passed Well Failed 3. No. of Radioactive Tracer/ Cement Bond Tests Well Passed Well Failed 4. (Specify) No. of Other Fluid Migration Tests/Evaluations Well Passed Well Failed

VII. Summary of Remedial

Action Total Wells A Number of Wells with Remedial Action

Total Remedial Actions B 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) VIII. Remarks/Ad Hoc Report (Attach additional sheets) 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. Certification

Signature and Typed or Printed Name and Title of Person Completing F or m Date Telephone No.
EPA Form 7520-3 (Rev. 12-11 ) Previous edition is obsolete.

## Instructions and Definitions All reporting is cumulative over the federal fiscal year, and includes activities from October 1- September 30. Please do not leave anything blank on this form. Enter a 0 if there are no wells that apply to the information requested; enter “NA” if the information does not apply to your program (e.g., if you do not oversee that class of well). 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. Total Inspections (this federal fiscal year to date): Item 1: For each well class, en ter the number of inspections to witness field Mechanical Integrity Tests. (At least 25% of MITs performed by operators each year should be witnessed.) Item 2: For each well class, enter the number of inspections that have been in response to a pr oblem reported to the regulating authority. Item 3: For each well class, ente r the number of inspections of well constructions or any preoperational activities. Item 4: For each well class, ente r 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 cha nnels adjacent to the well bore. An MIT consists of a field test on a well or an evaluation of a well’s monitoring records (i.e., annulus pressure, etc.) or cement records. At a minimum, the mechanical integrity of a Class I, II, or III (solution mining of salt) well should be demonstrated at least once every five years during the life of the well. Item A: For each well class, enter the total number of wells (i.e., permitted and rule authorized) that have had a complete MIT this federal fiscal year to date. Enter each well only once. Item B: For each well class, enter the number of rule authorized wells that have passed a complete MIT and the number that have failed a complete MIT this federal fiscal year to date.

EPA Form 7520-3 (11-14) Revised Item C: Significant Leak Tests: (This year to date) Items 1-4: For each well class, enter the number of times wells have passed or failed a field test/record evaluation for significant leaks. Item D: Fluid Migration Tests (thi s 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 integr ity (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 we ll. Remedial actions include additional permit conditions, monitoring, or testing. Item A: For each well class, enter the number of wells that have received remedial actions this federal fiscal year to date. Enter each well only once. Total Remedial Actions: (this fe deral fiscal year to date): Item 1-4: For each well class, en ter 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 es timated to average 5 hours per response. Burden means the tota l 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, in stall, 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 re quirements; train personnel to be able to respond to the collec tion of information; search data sources; complete and review the collection ofinformation; 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 unlessit 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 automate d 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.United States Environmental Protection Agency Washington, DC 20460

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

### UIC Federal Reporting System 

## Part IV: Quarterly Exceptions List Office of Ground Water and Drinking Water OMB No. 2040-0042 Approval expires 1 1/30/2014 I. Reporting Period From To

II. Well Class and Type III. Name and Address
of Owner/Operator IV. Well ID No. (Permit

No.) V. Summary of Violations VI. Summary of Enforcement VII. Date
Compliance

Achieved Date of

Violation Mark ('X') Violation Type Date of

Enforcement Mark ('X') Enforcement TypeUnauthorized InjectionWell Mechanical IntegrityInjection PressurePlugging and AbandonmentFormal OrderFalsificationOther (Specify)Notice of ViolationConsent AgreementAdministrative OrderCivil ReferralCriminal ReferralWell Shut-inPipeline SeveranceOther (Specify)

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. Certification

Signature of Person Completing Form Typed or Printed Name and Title Date Telephone No.

EPA Form 7520-4 (Rev. 12 -11) Previous edition is obsolete.

# Instructions and Definitions The Quarterly Exceptions list is used to track wells reported in significant noncompliance (SNC) on EPA Form 7520-2B for two or more consecutive quarters without being addressed with a formal enforcement action or being returned to compliance. Any SNC reported on Form 7520-4 shall be reported until the well in SNC is returned to compliance. The well is removed from the exceptions list in the subsequent reporting period. Section I - Reporting Period All reporting is cumulative over the federal fiscal year, and includes activities from October 1- March 31 (for midyear reporting) and from October 1- September 30 (for end of year reporting). Section II - Well Class and Type Enter the well class and type of each well in SNC for two or more consecutive quarters. For Class I wells, specify IH for hazardous waste, IM of municipal waste, Ii for industrial waste. For Class II wells, specify IID for saltwater disposal, IIR for enhanced recovery, IIH for liquid hydrocarbon storage. Section III - Name and Address of Owner/Operator Enter the name and address of the primary contact for the injection well. Use multiple lines of the form if needed. (You may use one form for each owner/operator.) Section IV - Well ID No. (Permit No.) Enter the primacy agency-assigned I.D. number of the injection well in SNC. If the well has a UIC permit number, enter this as the I.D. number. Section V - Summary of Violations Enter the date the SNC violation was first identified and place an “X” in the appropriate column. In the event that there were multiple SNC violations for a single well, enter each violation and the date it was identified on a separate line. Section VI - Summary of Enforcement Enter the date an enforcement action was taken against the SNC violation and place an “X” in the appropriate column. In the event that there were multiple enforcement actions, enter each enforcement action and the date it was taken on a separate line. Paperwork Reduction Act The public reporting and record keeping burden for this collection of information is estimated to average 2 hours per response. Burden m eans 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 in cludes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for th e 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 informat ion; 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 th e Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, DC 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.
EPA Form 7520-4 (11-14) RevisedOMB No. 2040-0042 Approval Expires 11/30/2014 United States Environmental Protection Agenc y

(Collected under the authority of the Safe Drinking Water Act. I. EPA ID Number 

### Underground Injection Control 

## Permit Application

Application approved Date received

Owner Name

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. imprisonment. XIV. Certification

A. Name and Title B. Phone No. A. U T/A C

Read Attached Instructions Before Starting For Official Use Only

Permit Number Well ID FINDS Number mo day year mo day year

Street Address City State ZIP CODE Phone Number II. Owner Name and Address III. Operator Name and Address Owner Name

Street Address City State ZIP CODE Phone Number

IV. Commercial Facility V. Ownership VI. Legal Contact VII. SIC Codes

Yes No Private Federal Other Owner Operator

VIII. Well Status (Mark "x") Date Started mo day year Operating B. Modification/Conversion C. Proposed

IX. Type of Permit Requested (Mark "x" and specify if required)

A. Class(es) B. Type(s) (enter code(s)) (enter code(s)) A. Individual B. Area Number of Existing Wells Number of Proposed Wells Name(s) of field(s) or project(s)

X. Class and Type of Well (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 XII. Indian Lands (Mark 'x') Latitude Longitude Deg Min Sec Deg Min Sec Township and Range 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.

(Type or Print) (Area Code and No.) C. Signature D. Date Signed Sections 1421, 1422, 40 CFR 144)

I am aware that there are significant penalties for submitting false information, including the possibliity of fine and (Ref. 40 CFR 144.32) Attach maps where List attachments by letter which are applicable and are included with your application.

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

## Well Class and Type Codes
Class I Wells used to inject waste below the deepest underground source of drinking water. Type “I” Nonhazardous industrial disposal well “M” Nonhazardous municipal disposal well “W” Hazardous waste disposal well injecting below USDWs “X” 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” Produced fluid disposal well “R” Enhanced recovery well “H” Hydrocarbon storage well (excluding natural gas) “X” Other Class II wells (not included in Type “D,” “R,” or “H”) Class III Special process injection wells. Type “G” Solution mining well “S” Sulfur mining well by Frasch process “U” Uranium mining well (excluding solution mining of conventional mines) “X” 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 A, B, C, D, F, H – S, U

existing A, B, C, D, F, H – U II new well A, B, C, E, G, H, M, Q, R; optional – I, J, K, O, P, U existing A, E, G, H, M, Q, R, – U; optional – J, K, O, P, Q III new well A, B, C, D, F, H, I, J, K, M – S, U existing A, B, C, D, F, H, J, K, M – U Other Classes To be specified by the permitting authority

EPA Form 7520-6 (12-11) 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 estimated to 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 h ours 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 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. 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. XIV. 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 6INSTRUCTIONS - 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, dry holes, 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 A description 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 the corrective 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 wells operating 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 6E. 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 OF GEOLOGIC STRUCTURE OF AREA - Submit maps and cross sections detailing the geologic structure of the local area (including the lithology of injection and confining intervals) and generalized 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 the injection zone and confining zones including lithologic description, geological name, thickness, depth and fracture pressure. H. OPERATING DATA - Submit the following proposed operating data for each 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 of the chemical, physical, radiological and biological characteristics, including density and corrosiveness, of injection fluids; (5) for Class II wells, source and analysis of the physical and chemical 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 be designed 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 drilli ng, 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 monitorin g 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 prog ram is utilized, pursuant to §146.23(b)(5), describe the program and compare it to individual well monitoring. Q. PLUGGING AND ABAN DONMENT 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 well in 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 of USDWs. Submit this information on EPA Form 7520-14, Plugging and Abandonment Plan. EPA Form 7520-6 Page 5 of 6R. 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 the aquifer 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 more than 3,000 and less than 10,000 mg/l and is not reasonably expected 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 the mining zone, analysis of the amenability of the mining zone to the proposed method, and time tabl e 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 6OMB No. 2040-0042 Approval Expires 11 /30/2014 United States Environmental Protection Agency Washington, DC 20460

Name and Address of Existing Permittee 

## Application To Transfer Permit

Locate Well and Outline Unit on Section Plat - 640 Acres

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.



### Certification

Name and Official Title Date Signed Name and Address of Surface Owner

State County Permit Number

N

W E

S Surface Location Description ____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of 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. Well Activity Well Status Type of Permit ____ Class I ____ Class II

____ Class III ____ Other ____ Brine Disposal ____ Enhanced Recovery ____ Hydrocarbon Storage

Lease Number Well Number ____ Operating ____ Modification/Conversion ____ Proposed ____ Individual ____ Area Number of Wells ____

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

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.

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.

(Please type or print) Signature significant penalties for submitting false information, including the possibility of fine and imprisonment . ( Ref
. 40 CFR 144.32 ) Range ____ Township ____ Section ____

I am aware that there are

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

## 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 maintainin g 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 c ollection 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. 

## Well Class and Type Code
Class I Wells used to inject waste below the deepest underground source of drinking water. Type “I” Nonhazardous industrial disposal well “M” Nonhazardous municipal disposal well “W” Hazardous waste disposal well injecting below USDWs “X” 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” Produced fluid disposal well “R” Enhanced recovery well “H” Hydrocarbon storage well (excluding natural gas) “X” Other Class II wells (not included in Type “D,” “R,” or “H”) Class III Special process injection wells. Type “G” Solution mining well “S” Sulfur mining well by Frasch process “U” Uranium mining well “X” Other Class III wells (not included in Type “G,” “S,” or “U”) Other Classes Wells not included in classes above. Class V wells which may be permitted under § 144.12 Wells not currently classified as Class I, II, III, or V

EPA Form 7520-7 (12-11) ReverseOMB No. 2040-0042 Approval Expires 11 /30/2014 United States Environmental Protection Agency Washington, DC 20460 

## Injection Well Monitoring Report
Year Month Month Month Injection Pressure (PSI)

1. Minimum 2. Average
3. Maximum Injection Rate (Gal/Min)

1. Minimum 2. Average
3. Maximum Annular Pressure (PSI)

1. Minimum 2. Average
3. Maximum Injection Volume (Gal)

1. Monthly Total 2. Yearly Cumulative Temperature (F °)

1. Minimum 2. Average
3. Maximum pH

1. Minimum 2. Average
3. Maximum Other

Name and Address of Permittee Permit Number

Name and Official Title (Please type or print) Signature Date Signed

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

### Paperwork Reduction Act The public reporting and record keeping burden for this collection of information is estimated to average 2 5 hours per qu a rte r for operators of Class I hazardous wells , 16 hours per quarter for operators of Class I nonhazardous wells, and 30 hours per quarter for operators of Class III wells. Burden means the total time, effort, or financial resource expended by pers ons 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 colle ction 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 techniqu es to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washing ton, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.

EPA Form 7520-8 ReverseO MB No. 2040-0042 Approval Expires 11/30/2014 United States Environmental Protection Agency Washington, DC 20460 

## Completion Form For Injection Wells Administrative Information 1. Permittee

Address (Permanent Mailing Address) (Street, City, and ZIP Code)

2. Operator

Address (Street, City, State and ZIP Code)

3. Facility Name Telephone Number

Address (Street, City, State and ZIP Code)

4. Surface Location Description of Injection Well(s) State County
Surface Location Description

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of Section ____ Township ____ Range ____ 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. Well Activity Well Status Type of Permit ____ Class I ____ Class II

____ Class III ____ Other ____ Brine Disposal ____ Enhanced Recovery ____ Hydrocarbon Storage

Lease Number _______________ Well Number _______________ ____ Operating ____ Modification/Conversion ____ Proposed ____ Individual ____ Area : Number of Wells ____

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

### 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) Signature Date Signed

EPA Form 7520-9 (Rev. 12-11 )PAPERWORK REDUCTION ACT The public reporting and record keeping burden for this collection of information is estimated to average 49 hours per response for a Class I hazardous facility, and 47 hours per response for a Class I non-hazardous facility. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to review instructions ; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining i nformation, 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 suggest ed methods for minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address. 

## Attachments to be submitted with the Completion report: I. Geologic Information 1. Lithology and StratigraphyA. Provide a geologic description of the rock units penetrated by name, age, depth, thickness, and lithology of each rock unit penetrated. B. Provide a description of the injection unit. (1) Name (2) Depth (drilled) (3) Thickness (4) Formation fluid pressure (5) Age of unit (6) Porosity (avg.) (7) Permeability (8) Bottom hole temperature (9) Lithology (10) Bottom hold pressure (11) Fracture pressure C. Provide chemical characteristics of formation fluid (attach chemical analysis). D. Provide a description of freshwater aquifers. (1) Depth to base of fresh water (less than 10,000 mg/l TDS). (2) Provide a geologic description of aquifer units with name, age, depth, thickness, lithology, and average total dissolved solids. II. Well Design and Construction 1. Provide data on surface, intermediate, and long string casing and tubing. Data must include material, size, weight, grade, and depth set. 2. Provide data on the well cement, such as type/class, additives, amount, and method of emplacement. 3. Provide packer data on the packer (if used) such as type, name and model, setting depth, and type of annular fluid used. 4. Provide data on centralizers to include number, type and depth. 5. Provide data on bottom hole completions. 6. Provide data on well stimulation used. III. Description of Surface Equipment 1. Provide data and a sketch of holding tanks, flow lines, filters, and injection pump. IV. Monitoring Systems 1. Provide data on recording and nonrecording injection pressure gauges, casing-tubing annulus pressure gauges, injection rate meters, temperature meters, and other meters or gauges. 2. Provide data on constructed monitor wells such as location, depth, casing diameter, method of cementing, etc. V. Logging and Testing Results Provide a descriptive report interpreting the results of geophysical logs and other tests. Include a description and data on deviation checks run during drilling. VI. Provide an as-built diagrammatic sketch of the injection well(s) showing casing, cement, tubing, packer, etc., with proper setting depths. The sketch should include well head and gauges. VII. Provide data demonstrating mechanical integrity pursuant to 40 CFR 146.08. VIII. Report on the compatibility of injected wastes with fluids and minerals in both the injection zone and the confining zone. IX. Report the status of corrective action on defective wells in the area of review. X. Include the anticipated maximum pressure and flow rate at which injection will operate.

EPA Form 7520-9 ReverseOMB No. 2040-0042 Approval Expires 11/30/2014 United States Environmental Protection Agency Washington, DC 20460

Name and Address of Existing Permittee 

### COMPLETION REPORT FOR BRINE DISPOSAL, HYDROCARBON STORAGE, OR ENHANCED RECOVERY

Locate Well and Outline Unit on Section Plat - 640 Acres



### Certification

Name and Official Title Date Signed Name and Address of Surface Owner

State County Permit Number

N

W E

S Surface Location Description ____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of 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. WELL ACTIVITY TYPE OF PERMIT Brine Disposal Enhanced Recovery Hydrocarbon Storage Individual Area Number of Wells ____

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. possibliity of fine and imprisonment. (Please type or print) Signature Estimated Fracture Pressure of Injection Zone
Anticipated Daily Injection Volume (Bbls) Injection Interval Average Maximum Feet to Feet Anticipated Daily Injection Pressure (PSI) Average Maximum Depth to Bottom of Lowermost Freshwater Formation (Feet)
Type of Injection Fluid (Check the appropriate block(s)) Lease Name Well Number Salt Water Brackish Water Fresh Water Liquid Hydrocarbon Other Name of Injection Zone Permeability of Injection Zone Porosity of Injection Zone Date Drilling Began Date Well Completed Date Drilling Completed

CASING AND TUBING CEMENT HOLE OD Size Depth Wt/Ft - Grade - New or Used Sacks Depth Class Bit Diameter

INJECTION ZONE STIMULATION WIRE LINE LOGS, LIST EACH TYPE Interval Treated Materials and Amount Used Log Types Logged Intervals

Complete Attachments A -- E listed on the reverse. Range ____ Township ____ Section ____

I am aware that there are significant penalties for submitting false information, including the (Ref. 40 CFR 144.32)

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

## ATTACHMENTS A. Present a schematic or other appropriate drawing of the surface and subsurface construction details of the well as built. B. Describe the method and results of mechanical integrity testing. C. Present the results of that portion of those logs, test, and cores which specifically relate to (1) underground sources of drinking water and the confining zone(s) and (2) the injection and adjacent formations. D. Present the status of corrective action on defective wells in the area of review. E. Provide to EPA, with the completion report, one final print of all geophysical logs run.

PAPERWORK REDUCTION ACT The public reporting and record keeping burden for this collection of information is estimated to average 4 hours per well. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or provide information t o 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 r equirements; train personnel to be able to respond to the collection of information; search data sources; complete and review the collection of in formation; and, transmit or otherwise disclose the information. An agency may not conduct or spo nsor, 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 accurac y 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., Was hington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.

EPA Form 7520-10 ReverseOMB No. 2040-0042 A pproval Expires 11/30/2014 United States Environmental Protection Agency Washington, DC 20460

Name and Address of Existing Permittee 

## ANNUAL DISPOSAL/INJECTION WELL MONITORING REPORT

Locate Well and Outline Unit on Section Plat - 640 Acres



### Certification

Name and Official Title Date Signed Name and Address of Surface Owner

State County Permit Number

N

W E

S Surface Location Description ____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of 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. WELL ACTIVITY TYPE OF PERMIT Brine Disposal Enhanced Recovery Hydrocarbon Storage Individual Area Number of Wells ____

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. possibliity of fine and imprisonment. (Please type or print) Signature INJECTION PRESSURE Lease Name Well Number

TOTAL VOLUME INJECTED TUBING -- CASING ANNULUS PRESSURE (OPTIONAL MONITORING) MONTH YEAR AVERAGE PSIG MAXIMUM PSIG BBL MCF MINIMUM PSIG MAXIMUM PSIG Range ____ Township ____ Section ____

I am aware that there are significant penalties for submitting false information, including the (Ref. 40 CFR 144.32)

EPA Form 7520-11 ( Rev . 12 -11 )PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is e stimated to average 30 hours per quarter
. Burden means the total time, effort, or financial r esource expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal Age ncy. This include s the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and ve rifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to co mply 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 min imizing respondent bu rden, including the use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania A ve., 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 ReverseOMB No. 2040-0042 A pproval Expires 11/30/2014 United States Environmental Protection Agency Washington, DC 20460

Name and Address of Permittee 

## WELL REWORK RECORD

Locate Well and Outline Unit on Section Plat - 640 Acres



### Certification

Name and Official Title Date Signed Name and Address of Contractor

State County Permit Number

N

W E

S Surface Location Description ____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of 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.

WELL ACTIVITY TYPE OF PERMIT Brine Disposal Enhanced Recovery Hydrocarbon Storage Individual Area Number of Wells ____

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. possibliity of fine and imprisonment. (Please type or print) Signature WELL CASING RECORD -- BEFORE REWORK Lease Name Well Number

Casing

DESCRIBE REWORK OPERATIONS IN DETAIL

USE ADDITIONAL SHEETS IF NECESSARY WIRE LINE LOGS, LIST EACH TYPE Log Types Logged Intervals Total Depth Before Rework
Total Depth After Rework

Date Rework Commenced
Date Rework Completed

Cement Perforations Acid or Fracture Treatment Record Size Depth Sacks Type From To

WELL CASING RECORD -- AFTER REWORK (Indicate Additions and Changes Only) Casing Cement Perforations Acid or Fracture Treatment Record Size Depth Sacks Type From To Range ____ Township ____ Section ____

I am aware that there are significant penalties for submitting false information, including the (Ref. 40 CFR 144.32)

EPA Form 7520-12 (R ev . 12-11)PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is estimated to average 4 hours per response annu ally. 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 disc losing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; t rain 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 accur acy 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 Pennsylva nia Ave., NW., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.

EPA Form 7520-12 ReverseOMB No. 2040-0042 A pproval E xpires 11/30/2014 United States Environmental Protection Agency Washington, DC 20460

Name and Address of Facility 

## PLUGGING AND ABANDONMENT PLAN

Locate Well and Outline Unit on Section Plat - 640 Acres



### Certification

Name and Official Title Date Signed Name and Address of Owner/Operator

State County Permit Number

N

W E

S Surface Location Description ____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of 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. WELL ACTIVITY TYPE OF AUTHORIZATION

Brine Disposal Enhanced Recovery Hydrocarbon Storage Individual Permit Area Permit

Number of Wells ____

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. possibliity of fine and imprisonment. (Please type or print) Signature CASING AND TUBING RECORD AFTER PLUGGING Lease Name Well Number

LIST ALL OPEN HOLE AND/OR PERFORATED INTERVALS AND INTERVALS WHERE CASING WILL BE VARIED (if any) From SIZE WT (LB/FT) TO BE PUT IN WELL (FT) TO BE LEFT IN WELL (FT) HOLE SIZE

CEMENTING TO PLUG AND ABANDON DATA: PLUG #1 Rule CLASS I CLASS II

CLASS III

METHOD OF EMPLACEMENT OF CEMENT PLUGS

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

PLUG #2 PLUG #3 PLUG #4 PLUG #5 PLUG #6 PLUG #7 Size of Hole or Pipe in which Plug Will Be Placed (inches) Depth to Bottom of Tubing or Drill Pipe (ft.) Sacks of Cement To Be Used (each plug) Slurry Volume To Be Pumped (cu. ft.) Calculated Top of Plug (ft.) Measured Top of Plug (if tagged ft.) Slurry Wt. (Lb./Gal.) Type Cement or Other Material (Class III)

From To To

Estimated Cost to Plug Wells Range ____ Township ____ Section ____

I am aware that there are significant penalties for submitting false information, including the (Ref. 40 CFR 144.32)

EPA Form 7520-14 (R ev. 12 -11)

### Paperwork Reduction Act Notice The public reporting and record keeping burden for this collection of information is estimated to average 4 .5 hours for operators of Class I hazardous wells, 1.5 hours for operators of Class I non-hazardous wells, 3 hours for operators of Class II wells, and 1.5 hours for operators of Class III wells. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to the collection of information; search data sources; complete and review the collection of information; and, transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control numbers for EPA’s regulations are listed in 40 CFR Part 9 and 48 CFR Chapter 15. Please send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques to Director, Office of Environmental Information, Collection Strategies Division, U.S. Environmental Protection Agency (2822), Ariel Rios Building, 1200 Pennsylvania Ave., NW., Washington, DC 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW., Washington, DC 20503, Attention: Desk Officer for EPA. Please include the EPA ICR number and OMB control number in any correspondence.

EPA Form 7520-14 ReverseType or print all information. See reverse for instructions. OMB No. 2040-0042 A pproval Expires 1 1/30/2014

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

### UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

## INVENTORY OF INJECTION WELLS

Deletion PAPERWORK REDUCTION ACT NOTICE 

### OFFICE OF GROUND WATER AND DRINKING WATER 1. DATE PREPARED 2. FACILITY ID NUMBER (Year, Month, Day)

The public reporting burden for this collection of information is estimated at about 0.5 hour per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. for reducing this burden, Director, Collection Strategies Division (2822), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 3. TRANSACTION TYPE (Please mark one of the following)

Entry Change First Time Entry Replacement 4. FACILITY NAME AND LOCATION A. NAME (last, first, and middle initial) C. LATITUDE
TOWNSHIP RANGE SECT . DEG MIN SEC E. TOWNSHIP/RANGE
1/4 SECT

. DEG MIN SEC D. LONGITUDE B. STREET ADDRESS/ROUTE NUMBER

F. CITY/TOWN G. STATE H. ZIP CODE I. NUMERIC COUNTY CODE J. INDIAN LAND (mark "x") Yes No 5. LEGAL CONTACT: A. TYPE (mark "x") Owner Operator C. PHONE (area code and number) B. NAME (last, first, and middle initial)

D. ORGANIZATION E. STREET/P.O. BOX

F. CITY/TOWN G. STATE H. ZIP CODE I. OWNERSHIP (mark "x") PRIVATE STATE PUBLIC FEDERAL SPECIFY OTHER

6. WELL INFORMATION: A. CLASS AND TYPE C. TOTAL NUMBER OF WELLS B. NUMBER OF WELLS D. WELL OPERATION STATUS COMM NON-COMM UC AC TA PA AN COMMENTS (Optional):

KEY: DEG = Degree MIN = Minute SEC = Second
SECT = Section 1/4 SECT = Quarter Section COMM = Commercial NON-COMM = Non-Commercial
AC = Active UC = Under Construction TA = Temporarily Abandoned PA = Permanently Abandoned and Approved by State AN = Permanently Abandoned and not Approved by State Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions 20503. 20460, and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC

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

## INSTRUCTIONS AND DEFINITIONS SECTION 1. DATE PREPARED: Enter date in order of year, month, and day. SECTION 2. FACILITY ID NUMBER: In the first two spaces, insert the appropriate U.S. Postal Service State Code. In the third space, insert one of the following one letter alphabetic identifiers: D - DUNS Number, G - GSA Number, or S - State Facility Number. In the remaining spaces, insert the appropriate nine digit DUNS, GSA, or State Facility Number. For example, A Federal facility (GSA - 123456789) located in Virginia would be entered as : VAG123456789. SECTION 3. TRANSACTION TYPE: Place an “x” in the applicable box. See below for further instructions.

Deletion. Fill in the Facility ID Number. First Time Entry. Fill in all the appropriate information. Entry Change. Fill in the Facility ID Number and the information that has changed. Replacement. SECTION 4. FACILITY NAME AND LOCATION:

A. Name. Fill in the facility’s official or legal name. B. Street Address. Self Explanatory. C. Latitude. Enter the facility’s latitude (all latitudes assume North Except for American Samoa). D. Longitude. Enter the facility’s longitude (all longitudes assume West except Guam). E. Township/Range. Fill in the complete township and range. The first 3 spaces are numerical and the fourth is a letter (N,S,E,W) specifying a compass direction. A township is North or South of the baseline, and a range is East or West of the principal meridian (e.g., 132N, 343W). F. City/Town. Self Explanatory. G. State. Insert the U.S. Postal Service State abbreviation. H. Zip Code. Insert the five digit zip code plus any extension. SECTION 4. FACILITY NAME & LOCATION (CONT’D.): I. Numeric County Code. Insert the numeric county code from the Federal Information Processing Standards Publication (FIPS Pub 6-1) June 15, 1970, U.S. Department of Commerce, National Bureau of Standards. For Alaska, use the Census Division Code developed by the U.S. Census Bureau. J. Indian Land. Mark an “x” in the appropriate box (Yes or No) to indicate if the facility is located on Indian land. SECTION 5. LEGAL CONTACT:

A. Type. Mark an “x” in the appropriate box to indicate the type of legal contact (Owner or Operator). For wells operated by lease, the operator is the legal contact. B. Name. Self Explanatory. C. Phone. Self Explanatory. D. Organization. If the legal contact is an individual, give the name of the business organization to expedite mail distribution. E. Street/P.O. Box. Self Explanatory. F. City/Town. Self Explanatory. G. State. Insert the U.S. Postal Service State abbreviation. H. Zip Code. Insert the five digit zip code plus any extension. I. Ownership. Place an “x” in the appropriate box to indicate ownership status. SECTION 6. WELL INFORMATION:

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

## INJECTION WELL CLASS AND TYPE CODES CLASS I Industrial, Municipal, and Radioactive Waste Disposal Wells used to inject waste below the lowermost Underground Source of Drinking Water (USDW).
TYPE 1I Non-Hazardous Industrial Disposal Well. 1M Non-Hazardous Municipal Disposal Well. 1H Hazardous Waste Disposal Well injecting below the lowermost USDW. 1R Radioactive Waste Disposal Well. 1X Other Class I Wells. CLASS II Oil and Gas Production and Storage Related Injection Wells.
TYPE 2A Annular Disposal Well. 2D Produced Fluid Disposal Well. 2H Hydrocarbon Storage Well. 2R Enhanced Recovery Well. 2X Other Class II Wells. CLASS III Special Process Injection Wells.
TYPE 3G In Situ Gasification Well 3M Solution Mining Well. CLASS III (CONT’D.)
TYPE 3S Sulfur Mining Well by Frasch Process. 3T Geothermal Well. 3U Uranium Mining Well. 3X Other Class III Wells. CLASS IV Wells that inject hazardous waste into/above USDWs.
TYPE 4H Hazardous Facility Injection Well. 4R Remediation Well at RCRA or CERCLA site. CLASS V Any Underground Injection Well not included in Classes I through IV.
TYPE 5A Industrial Well. 5B Beneficial Use Well. 5C Fluid Return Well. 5D Sewage Treatment Effluent Well. 5E Cesspools (non-domestic). 5F Septic Systems. 5G Experimental Technology Well. 5H Drainage Well. 5I Mine Backfill Well. 5J Waste Discharge Well. EPA Form 7520-16 (Revised 12-11)PAPERWORK REDUCTION ACT The public reporting and record keeping burden for this collection of information is estimated to average 0.5 hours per response. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to the collection of information; search data sources; complete and review the collection of information; and, transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.

EPA Form 7520-16 (Revised 12-11)

### United States Environmental Protection Agenc y UIC Federal Reporting Syste m 

# Class V Well Pre-Closure Notification For m

1

. Name of facility : Address of facility : City/Town : State : Zip Code : County : Location : Lat./Long. : 2

. Name of Owner/Operator :

Address of Owner/Operator : City/Town : State : Zip Code : Legal contact : Phone number : 3

. Type of well(s) : Number of well(s) : 4

. Well construction (check all that apply) :

Drywel l Septic tan k Cesspoo l Improved sinkhol e Drainfield/leachfiel d Othe r 5

. Type of discharge :
6

. Average flow (gallons/day) : 7. Year of well construction : 8

. Type of well closure (check all that apply) :

Sample fluids/sediment s Clean out wel l Appropiate disposal of remaining fluids/sediment s Install permanent plu g Remove well & any contaminated soi l Conversion to other well typ e Other (describe) : 9

. Proposed date of well closure : 10

. Name of preparer : Date :

Certificatio n I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this doc u ment and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the info rmation, I believe that the information is true, accurate, and complete. I am aware that there are significant penalties for su b

mitting false information, including the possibility of fine and imprisonment. (Ref. 40 CFR 144.32)

. Name and Official Title ( Please type or prin t ) Signatur e Date Signe d Type or print all information. See reverse for instruction s Form Approved 12/99 OMB No. 2040-021 4

EPA Form 7520-1 7INSTRUCTIONS FOR EPA FORM 7520-17 This form contains the minimum information that you must provide your UIC Program Director if you intend to close your Class V well. This form will be used exclusively where the EPA administers the UIC Program: AK, AS, AZ, CA, CO, DC, DE, HI, IA, IN, KY, MI, MN, MT, NY, PA, SD, TN, VA, V I, and on all Tribal Lands. If you are located in a different State or jurisdiction, ask the agency that administers the UIC Program in your State for the appropriate form. If you are closing two or more Class V wells that are of similar construction at your facility (two dry wells, for example) you may use one form. If you are closing Class V wells of different construction (a septic system and a dry well, for example) use one form per construction type. The numbers below correspond to the numbers on the form. 1. Supply the name and street address of the facility where the Class V well(s) is located. Include the City/Town, State (U.S. Postal Service abbreviation) and Zip Code. If there is no street address for the Class V well, provide the route number or locate the well(s) on a map and attach it to this form. Under "Location," provide the Latitude/Longitude of the well, if available. 2. Provide the name and mailing address of the owner of the facility, or if the facility is operated by lease, the operator of the facility. Include the name and phone number of the legal contact for any questions regarding the information provided on this form. 3. Indicate the type of Class V well that you intend to close (for example, motor vehicle waste disposal well or cesspool). Provide the number of wells of this well type at your location that will be closed.4. Mark an "X" in the appropriate box to indicate the type of well construction. Mark all that apply to your situation. For example, for a septic tank that drains into a drywell, mark both the "septic tank" and "drywell" boxes. Please provide a generalized sketch or schematic of the well construction if available. 5. 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. 6. Estimate the average daily flow into the well in gallons per day. 7. 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. 8. Mark an "X" in the appropriate box(s) to indicate briefly how the well closure is expected to proceed. Mark all that apply to your situation. For example, all boxes except the "Remove well & any contaminated soil" and "Other" would be marked if: the connection of an automotive service bay drain leading to a septic tank and drainfield will be closed, but the septic system will continue to be used for washroom waste disposal only, and the fluids and sludge throughout the system will be removed for proper disposal, the system cleaned, a ce mentplug placed in the service bay drain and the pipe leading to the washroom connection, and the septic tank/drainfield remains open for septic use only. In this example, the motor vehicle waste disposal well is being converted to another well type (a large capacity septic system). 9. Self explanatory. 10. Self explanatory. PLEASE READ . . . The purpose of this form is to serve as the means for the Class V well owner or operator’s notice to the UIC Director of his/her intent to close the well in accordance with Title 40 of the Code of Federal Regulations (40 CFR) Section 144.12(a). According to 40 CFR §144.86, you must notify the UIC Program Director at least 30 days prior to well closure of your intent to close and abandon your well. Upon receipt of this form, if the Director determines that more specific information is required to be submitted to ensure that the well closure will be conducted in a manner that will protect underground sources of drinking water (as defined in 40 CFR §144.3), the Director can require the owner/operator to prepare, submit and comply with a closure plan acceptable to, and approved by the Director. Please be advised that this form is intended to satisfy Federal UIC requirements regarding pre-closure notification only. Other State, Tribal or Local requirements may also apply.
Paper Work Reduction Act Notice The public reporting and record keeping burden for this collection of information is estimated to average 1.5 hours per respond ent. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provid einformation 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, a nd disclosing and providing information, adjust the existing ways to comply with any previously applicable instructions and require

ments; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not requir ed to respond to, a collection of information unless it displays a currently valid OMB control number.Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including thorough the use of automated collection techniques to the Director, Regulatoryinformation Division, U.S. Environmental Protection Agency (2137), 401 M. Street, S.W., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form 7520-17