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 Disposal, 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 Form
Please type or print all information. Please read instructions. OMB No. 2040-0042 Form Expires 11/30/2014 

United States Environmental Protection Agency 

Office of Ground Water and Drinking Water 

Washington, DC 20460 

(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. 

Permit 

Determination 

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Number of Permits Denied/Withdrawn 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 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. 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 the approval or denial of UIC 

permit requests/actions such as: applications for permits, major 

modifications to issued permits, revocation and reissuance of 

permits, or termination of permits for cause. A complete permit 

determination includes a thorough technical evaluation of the 

request, public notification or review before issuance, and a final 

decision document signed by the regulating authority. 

Item A: For each well class, enter the number of individual 

permits issued for “New” or “Existing” wells this federal fiscal 

year to date. 

Item B: For each well class, enter the number of area permits that 

have been issued for “New” or “Existing” well fields this year to 

date. (“New” in this case, describes a nonhazardous injection well 

field having only new wells or a mixture of new and existing wells. 

“Existing” describes a nonhazardous well field that has existing 

wells only.) 

Item C: For each well class, enter the number of “New” and 

“Existing” wells covered by the Area Permits entered in Item B. 

Item D: For each well class, enter the number of permits or major 

modifications denied by the UIC primacy program and/or permits 

withdrawn by applicants this federal fiscal year to date. The denial 

of a permit or major modification should be included as a permit 

determination only after there has been a complete technical 

review. 

Item E: For each well class, enter the number of major modifications approved this federal fiscal year to date. An approved major 

modification requires a complete technical review, public 

notification or review, and a final decision document signed by the 

regulating authority. 

Section VII. Permit File Review

A complete technical review of an existing (rule authorized) Class 

II well record may be conducted to determine whether the well is 

in compliance with UIC regulatory requirements in lieu of a permit 

determination. The well record (or file) review may include an 

evaluation of siting reports, wells in the area of review, 

construction, operating, monitoring or other reports. Existing Class 

II wells should be routinely reviewed at least once every five years 

during the life of the well. 

Wells Reviewed: For rule authorized (existing) Class II wells only, 

enter the number of wells with permit files reviewed and 

compliance status determined this federal fiscal year to date. 

Wells Deficient: For rule authorized Class II wells, enter the 

number of reviewed wells that were found deficient (not in 

compliance with UIC regulations). 

Section 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, enter the number of “Abandoned” and 

“Other” wells reviewed in the AoR for each permit application or 

file that has been reviewed this federal fiscal year to date. 

“Abandoned” includes any well penetrating the injection zone in the 

AoR that has been properly or improperly plugged and/or 

abandoned. 

“Other” includes any producing well, operable injection well, dry 

hole, exploratory well, etc., that penetrates the injection zone in the 

AoR. 

Corrective Action is required for those wells that penetrate the 

injection zone in the AoR that are improperly sealed, completed, or 

abandoned. 

Item B: For each well class, enter the number of “Abandoned” and 

“Other” wells in the AoR that have required corrective action for 

each permit application or file reviewed this federal fiscal year to 

date. 

Item C: For each well class, enter the number of wells in the AoR 

which have received corrective action (be specific) for all permit 

applications or files that have been reviewed this year to date. 

Paperwork Reduction Act Notice

The public reporting and record keeping burden for this collection 

of information is estimated to average 4.5 hours per year. Burden 

means the total time, effort, or financial resource expended by 

persons to generate, maintain, retain, or disclose or provide 

information to or for a Federal Agency. This includes the time 

needed to review instructions; develop, acquire, install, and 

utilize technology and systems for the purposes of collecting, 

validating, and verifying information, processing and maintaining 

information, and disclosing and providing information; adjust the 

existing ways to comply with any previously applicable 

instructions and requirements; train personnel to be able to 

respond to the collection of information; search data sources; 

complete and review the collection of information; and, transmit 

or otherwise disclose the information. An agency may not 

conduct or sponsor, and a person is not required to respond to, a 

collection of information unless it displays a currently valid OMB 

control number. Send comments on the Agency’s need for this 

information, the accuracy of the provided burden estimates, and 

any suggested methods for minimizing respondent burden, 

including the use of automated collection techniques to Director, 

Collection Strategies Division, U.S. Environmental Protection 

Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 

20460. Include the OMB control number in any correspondence. 

Do not send the completed forms to this address. 

EPA Form 7520-1 (11-14) Revised 
Please type or print all information. Please read instructions on reverse. OMB No. 2040-0042 Approval Expires 11/30/2014

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 

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 

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 your program (e.g., if you do not 

oversee that class of well).

A Class I, II, III, IV, or V injection well with a violation of a permit or 

rule requirement is said to be in noncompliance. Note: A well with 

certain types of violations may also be in significant noncompliance. 

(See Form 7520-2B (Reverse) for definitions of SNC violations.) 

Section V. Summary of Violations

(Includes all noncompliance, significant and non-significant) 

A. Total Wells: For each well class, enter the number of wells with 

one or more violations in this federal fiscal year to date. Enter each 

well only once. Include all wells with violations, even those with 

violations that have been returned to compliance. 

B. Total Violations: 

Items 1-6: For each well class, enter the number of times each 

violation type has been identified this federal fiscal year to date. 

Section VI. Summary of Enforcement

A. Total Wells: For each well class, enter the number of wells with 

violations that have been addressed by the specific type of 

enforcement action indicated in the row, in this federal fiscal year to 

date. Enter each well only once. 

B. Total Enforcement Actions:

Items 1-8: For each well class, enter the number of times wells with 

violations been addressed by the specific type of enforcement action 

indicated in the row, in this federal fiscal year to date. (Count draft and 

final Administrative Orders together.) 

Section VII. Number of Wells Returned to Compliance 

A “Well Returned to Compliance” is a well that has all underlying 

violations resolved and compliance has been verified by the primacy 

program. Note: An enforcement action alone (e.g., well shut-in) does 

not constitute a “return to compliance;” however, plugging and 

abandonment does constitute a return to compliance. 

A. For each well class, enter the number of wells returned to 

compliance in the current quarter only. 

B. For each well class, enter the number of wells returned to 

compliance this federal fiscal year to date. Enter each well only 

once. 

Section VIII. USDW Contaminations

For each well class, enter the number of times a well in noncompliance 

has allegedly contaminated an underground source of drinking water 

(USDW) this federal fiscal year to date. 

Section IX. Percent of MIT Violations Resolved in 90 Days

For each well class, enter the percentage of MIT violations resolved 

within 90 days as of the end of the reporting period. 

 Mechanical Integrity violations are as defined in Section V, under 

“Mechanical Integrity.” 

 Resolved is defined as returned to compliance (per Section VII). 

 MI violations not associated with loss of mechanical integrity 

(such as reporting) are not counted under this section. 

 Violations occurring WITHIN 90 days of September 30 should 

be included in reporting for the following federal fiscal year. 

To calculate the percentage: 

 Add up the total number of MIT violations that occurred within 

the year prior to the reporting cutoff. 

 Add up the number of these violations that were resolved within 

90 days as of 3/31(for midyear reporting) or as of 9/30 (for end of 

year reporting). 

 Calculate the percentage of total MIT violations that were 

resolved in 90 days or less. 

Example for Midyear reporting: 

 Number of violations that occurred from 7/1 – 3/31 = 8 

 Number of these violations resolved within 90 days as of 3/31 = 2 

 Percentage of MIT violation resolved within 90 days = 25% 

Example for End of Year reporting: 

 Number of MIT violations that occurred from 7/1 – 6/30 = 10 

o 8 from midyear plus 2 additional (4/1 to 6/30) 

 Number of these violations resolved within 90 days as of 9/30 = 5 

o 2 (from midyear) + 3 (from 4/1 to 6/30) 

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

Paperwork Reduction Act

The public reporting and record keeping burden for this collection of 

information is estimated to average 6 hours per response. Burden 

means the total time, effort, or financial resource expended by 

persons to generate, maintain, retain, or disclose or provide 

information to or for a Federal Agency. This includes the time 

needed to review instructions; develop, acquire, install, and utilize 

technology and systems for the purposes of collecting, validating, 

and verifying information, processing and maintaining information, 

and disclosing and providing information; adjust the existing ways 

to comply with any previously applicable instructions and 

requirements; train personnel to be able to respond to the collection 

of information; search data sources; complete and review the 

collection of information; and, transmit or otherwise disclose the 

information. An agency may not conduct or sponsor, and a person is 

not required to respond to, a collection of information unless it 

displays a currently valid OMB control number. Send comments on 

the Agency’s need for this information, the accuracy of the provided 

burden estimates, and any suggested methods for minimizing 

respondent burden, including the use of automated collection 

techniques to Director, Collection Strategies Division, U.S. 

Environmental Protection Agency (2822), 1200 Pennsylvania Ave., 

NW., Washington, D.C. 20460. Include the OMB control number in 

any correspondence. Do not send the completed forms to this 

address. 

EPA Form 7520-2A (11-14) Revised 
Please type or print all information. Please read instructions on reverse. OMB No. 2040-0042 Approval Expires 11/30/2014

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 

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 

Item 

Class and Type of Injection Wells 

I 

II 

III IV V 

SWD 

2D 

ER 

2R 

HC 

2H 

V. 

Summary 

of 

Significant 

NonCompliance 

(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 

Against SNC Violations (Specify)

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 obsolete. 
Instructions and Definitions

Section IV. Reporting Period: All reporting is cumulative over the 

federal fiscal year, and includes activities from October 1- March 31 (for 

midyear reporting) and from October 1- September 30 (for end of year 

reporting). 

Please do not leave anything blank on this form. Enter a 0 if there are 

no wells that apply to the information requested; enter “NA” if the 

information does not apply to your program (e.g., if you do not oversee 

that class of well). 

Note: Significant Noncompliance violations are a subset of the violations 

reported on EPA Form 7520-2A. 

Definitions of SNC Violations: SNC violations are violations that 

endanger or pose a significant potential to endanger underground sources 

of drinking water (USDWs), and violations that are not addressed after 

enforcement actions. For example: 

1. The following violations for a Class I well: 

a. Contamination of a USDW; 

b. Injection of unauthorized fluid(s); 

c. Injection into unauthorized zones; 

d. Failure to cease injection after loss of MI detected; Failure to 

comply with corrective action requirements; 

e. Failure to operate automatic shutdown system; 

f. Failure to operate automatic warning system; 

g. Unauthorized plugging and abandonment; 

h. Violation of a Formal Order; 

i. Knowing submission of false information; 

j. Violations involving loss of mechanical integrity; 

k. Violations of maximum injection pressure; 

l. Failure to install and/or operate injection pressure and annulus 

pressure monitoring systems or other monitoring systems, required 

by permit or rule; and 

m. Failure to maintain required annulus pressure. 

Also, any Class I well with a non-SNC violation that is noted three times 

within twelve months of the first violation is considered to be in SNC. 

2. The following violations for a Class II, III, or V well: 

a. Unauthorized Injection – Any unauthorized emplacement of fluids 

(where formal authorization is required); 

b. Mechanical Integrity – Well operation without mechanical integrity 

which causes the movement of fluid outside the authorized zone – if 

injection of such fluid may have the potential for endangering a 

USDW; 

c. Injection Pressure – Well operation at an injection pressure that 

exceeds the permitted or authorized injection pressure and causes 

the movement of fluid outside the authorized zone of injection – if 

such movement may have the potential for endangering a USDW; 

d. Plugging and Abandonment – The plugging and abandonment of an 

injection well in an unauthorized manner. These wells are in SNC 

only when there is endangerment of USDW and there is an 

identifiable owner/operator; 

e. Violation of a Formal Order – Any violation of a formal 

enforcement action, including an administrative or judicial order, 

consent agreement, judgment, or equivalent action; or 

f. Falsification – The knowing submission or use of any false 

information in a permit application, periodic report or special 

request for information about a well. 

3. Any violation for a Class IV well. 

EPA Form 7520-2B (11-14) Revised 

Section V. Total No. of Wells with SNC Violations: Significant 

Noncompliance violations are a subset of the violations reported on EPA 

From 7520-2A. For each well class, enter the number wells with SNC 

violations identified in the federal fiscal year to date. Report the well even 

if the violation has been corrected. Count each well only once. 

For each well class in subsections 1 through 7, enter the number the number 

of times each SNC violation has been identified this federal fiscal year to 

date. 

Section VI. Total SNC Enforcement Actions: Significant Noncompliance violations are a subset of the violations reported on EPA Form 

7520-2A. For each well class, enter the number of wells with SNC 

violations that have received an enforcement action(s) this year to date. 

Report the well even if the violation has been corrected. Count each well 

only once. 

For each well class in subsections 1 through 7, enter the number of times 

wells with SNC violations have received each type enforcement action this 

federal fiscal year to date. 

Section VII. No. of Wells Returned to Compliance: “Well Returned to 

Compliance” is a well that has all underlying violations resolved and 

compliance has been verified by the primacy program. Note: an 

enforcement action alone (e.g., well shut-in) does not constitute a “return 

to compliance;” however, plugging and abandonment does constitute a 

return to compliance.

For each well class in subsection A, enter the number of wells returned to 

compliance (as a result of an enforcement action against a SNC violation). 

For each well class in subsection B, enter the number of wells returned to 

compliance (as a result of an enforcement action against an SNC violation) 

this federal fiscal year to date. Enter each well only once. 

Section VIII. USDW Contaminations: For each well class, enter the 

number of times a well in SNC has allegedly contaminated a USDW this 

federal fiscal year to date. 

Section IX. Number of Class IV/V Endangering Class V Well Closures: For Class IV and Class V wells, enter the number of voluntary or 

involuntary well closures. 

Voluntary well closure means well closed as a direct result of outreach 

activities. 

Involuntary well closure means wells closed as a result of enforcement 

actions or permit call-ins. 

Well closure describes a process to permanently discontinue injection in 

accordance with the UIC regulations. 

Paperwork Reduction Act

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

estimated to average 5.5 hours per response. Burden means the total time, effort, or 

financial resource expended by persons to generate, maintain, retain, or disclose or 

provide information to or for a Federal Agency. This includes the time needed to 

review instructions; develop, acquire, install, and utilize technology and systems for the 

purposes of collecting, validating, and verifying information, processing and 

maintaining information, and disclosing and providing information; adjust the existing 

ways to comply with any previously applicable instructions and requirements; train 

personnel to be able to respond to the collection of information; search data sources; 

complete and review the collection of information; and, transmit or otherwise disclose 

the information. An agency may not conduct or sponsor, and a person is not required to 

respond to, a collection of information unless it displays a currently valid OMB control 

number. Send comments on the Agency’s need for this information, the accuracy of the 

provided burden estimates, and any suggested methods for minimizing respondent 

burden, including the use of automated collection techniques to Director, Collection 

Strategies Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania 

Ave., NW., Washington, DC 20460. Include the OMB control number in any 

correspondence. Do not send the completed forms to this address. 
Please type or print all information. Please read instructions on reverse. OMB No. 2040-0042 Approval Expires 11/30/2014

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 

Item 

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 Form 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, enter the number of inspections to 

witness field Mechanical Integrity Tests. (At least 25% of MITs 

performed by operators each year should be witnessed.) 

Item 2: For each well class, enter the number of inspections that 

have been in response to a problem reported to the regulating 

authority. 

Item 3: For each well class, enter the number of inspections of 

well constructions or any preoperational activities. 

Item 4: For each well class, enter the number of inspections of 

plugging and abandonment. 

Item 5: For each well class, enter the number of inspections that 

have been routine / periodic. 

Section VI. Summary of Mechanical Integrity

A complete MIT is composed of a test for significant leaks in the 

casing, tubing or packer and a test for significant fluid migration 

into a USDW through vertical channels adjacent to the well bore. 

An MIT consists of a field test on a well or an evaluation of a 

well’s monitoring records (i.e., annulus pressure, etc.) or cement 

records. At a minimum, the mechanical integrity of a Class I, II, 

or III (solution mining of salt) well should be demonstrated at 

least once every five years during the life of the well. 

Item A: For each well class, enter the total number of wells (i.e., 

permitted and rule authorized) that have had a complete MIT this 

federal fiscal year to date. Enter each well only once. 

Item B: For each well class, enter the number of rule authorized

wells that have passed a complete MIT and the number that have 

failed a complete MIT this federal fiscal year to date. 

EPA Form 7520-3 (11-14) Revised 

Item C: Significant Leak Tests: (This year to date) 

Items 1-4: For each well class, enter the number of times wells 

have passed or failed a field test/record evaluation for significant 

leaks. 

Item D: Fluid Migration Tests (this federal fiscal year to date): 

Items 1-4: For each well class, enter the number of times wells 

have passed or failed a field test/record evaluation for fluid 

migration. 

Section VII. Summary of Remedial Action

A failure of mechanical integrity (MI) may occur at any time 

during the life of an injection well. Failure may be identified 

during an inspection, a field test, an evaluation of well records, or 

during routine operation of a well. Remedial actions include 

additional permit conditions, monitoring, or testing. 

Item A: For each well class, enter the number of wells that have 

received remedial actions this federal fiscal year to date. Enter 

each well only once. 

Total Remedial Actions: (this federal fiscal year to date): 

Item 1-4: For each well class, enter the number of times that wells 

have received remedial action. 

Paperwork Reduction Act

The public reporting and record keeping burden for this 

collection of information is estimated to average 5 hours per 

response. Burden means the total time, effort, or financial 

resource expended by persons to generate, maintain, retain, 

or disclose or provide information to or for a Federal 

Agency. This includes the time needed to review 

instructions; develop, acquire, install, and utilize technology 

and systems for the purposes of collecting, validating, and 

verifying information, processing and maintaining 

information, and disclosing and providing information; 

adjust the existing ways to comply with any previously 

applicable instructions and requirements; train personnel to 

be able to respond to the collection of information; search 

data sources; complete and review the collection of 

information; and, transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is 

not required to respond to, a collection of information unless 

it displays a currently valid OMB control number. Send comments on the Agency’s need for this information, the 

accuracy of the provided burden estimates, and any 

suggested methods for minimizing respondent burden, 

including the use of automated collection techniques to 

Director, Collection Strategies Division, U.S. Environmental 

Protection Agency (2822), 1200 Pennsylvania Ave., NW., 

Washington, DC 20460. Include the OMB control number in 

any correspondence. Do not send the completed forms to this 

address. 
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 11/30/2014

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 Type 

Unauthorized Injection Well Mechanical Integrity Injection Pressure Plugging and Abandonment Formal Order Falsification Other (Specify) Notice of Violation Consent Agreement Administrative Order Civil Referral Criminal Referral Well Shut-in Pipeline Severance Other (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 means the total time, effort, 

or financial resource expended by persons to generate, 

maintain, retain, or disclose or provide information to or 

for a Federal Agency. This includes the time needed to 

review instructions; develop, acquire, install, and utilize 

technology and systems for the purposes of collecting, 

validating, and verifying information, processing and 

maintaining information, and disclosing and providing 

information; adjust the existing ways to comply with 

any previously applicable instructions and 

requirements; train personnel to be able to respond to 

the collection of information; search data sources; 

complete and review the collection of information; and, 

transmit or otherwise disclose the information. An 

agency may not conduct or sponsor, and a person is not 

required to respond to, a collection of information 

unless it displays a currently valid OMB control 

number. Send comments on the Agency’s need for this 

information, the accuracy of the provided burden 

estimates, and any suggested methods for minimizing 

respondent burden, including the use of automated 

collection techniques to Director, Collection Strategies 

Division, U.S. Environmental Protection Agency 

(2822), 1200 Pennsylvania Ave., NW., Washington, 

DC 20460. Include the OMB control number in any 

correspondence. Do not send the completed forms to 

this address. 

EPA Form 7520-4 (11-14) Revised 
OMB No. 2040-0042 Approval Expires 11/30/2014

United States Environmental Protection Agency 

(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 hours for a Class III well application. Burden means the total time, effort, or financial resource expended by 

persons to generate, maintain, retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to 

review instructions;develop,acquire,install, and utilize technology and systems for the purposes of collecting,validating,and verifying 

information,processing and maintaining information, and disclosing andproviding information;adjustthe existing ways to complywith 

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 collectionofinformation 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 6 
INSTRUCTIONS - Attachments 

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

A. AREA OF REVIEW METHODS - Give the methods and, if appropriate, the calculations used to determine the size of 

the area of review (fixed radius or equation). The area of review shall be a fixed radius of 1/4 mile from the well bore 

unless the use of an equation is approved in advance by the Director. 

B. MAPS OF WELL/AREA AND AREA OF REVIEW - Submit a topographic map, extending one mile beyond the property 

boundaries, showing the injection well(s) or project area for which a permit is sought and the applicable area of 

review. The map must show all intake and discharge structures and all hazardous waste treatment, storage, or 

disposal facilities.If the application is for an area permit, the map should show the distribution manifold (ifapplicable) 

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 ofall producing wells,injection wells, abandoned wells,dryholes, surface bodies 

of water, springs, mines (surface and subsurface), quarries, and other pertinent surface features, including 

residences and roads,and faults,if known or suspected.In addition,the map must identify thosewells,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 PLANANDWELL DATA - Submita tabulation of data reasonably available from public records 

or otherwise known to the applicant on all wells within the area of review, including those on the map required in B, 

which penetrate the proposed injection zone. Such data shall include the following: 

Class I 

Adescription ofeach well's types,construction,date drilled,location,depth,record ofplugging 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 wellsoperating overthe fracture pressure ofthe injection 

formation, all known wells within the area ofreview which penetrate formations affected by the increase in pressure. 

This requirement does not apply to existing Class II wells. 

Class III 

In addition to requirements for Class I, the corrective action proposed under 40 CFR 144.55 for all Class III wells. 

D. MAPS AND CROSS SECTION OF USDWs - Submit maps and cross sections indicating the vertical limits of all 

underground sources of drinking water within the area of review (both vertical and lateral limits for Class I), their 

position relative to the injection formation and the direction of water movement, where known, in every underground 

source of drinking water which may be affected by the proposed injection. (Does not apply to Class II wells.) 

EPA Form 7520-6 Page 4 of 6 
E. NAME AND DEPTH OF USDWs (CLASS II) - For Class II wells, submit geologic name, and depth to bottom of all 

underground sources of drinking water which may be affected by the injection. 

F. MAPS ANDCROSSSECTIONS OFGEOLOGICSTRUCTUREOF AREA - Submit maps and cross sections detailing the 

geologic structure ofthe local area (including the lithology of injection and confining intervals) andgeneralized maps 

and cross sections illustrating the regional geologic setting. (Does not apply to Class II wells.) 

G. GEOLOGICAL DATA ON INJECTION AND CONFINING ZONES (Class II) - For Class II wells, submit appropriate 

geological data ontheinjectionzone 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 dailyrate and volumeofthe 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 andranges in concentrations ofall constituents ofinjected 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 Iwells the program 

must be designed to obtain data on fluid pressure, temperature, fracture pressure, other physical, chemical, and 

radiological characteristics of the injection matrix and physical and chemical characteristics of the formation fluids. 

For Class II wells the testing program must be designed to obtain data on fluid pressure, estimated fracture 

pressure, physical and chemical characteristics of the injection zone. (Does not apply to existing Class II wells or 

projects.) 

For Class III wells the testing must bedesigned to obtain data on fluid pressure,fracture pressure, and physical and 

chemical characteristics of the formation fluids if the formation is naturally water bearing. Only fracture pressure is 

required if the program formation is not water bearing. (Does not apply to existing Class III wells or projects.) 

J. STIMULATION PROGRAM - Outline any proposed stimulation program. 

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

L. CONSTRUCTIONPROCEDURES - Discuss the construction procedures (according to §146.12 for Class I, §146.22 for 

Class II, and §146.32 for Class III) to be utilized. This should include details of the casing and cementing program, 

logging procedures, deviation checks, and the drilling, testing and coring program, and proposed annulus fluid. 

(Request and submission of justifying data must be made to use an alternative to packer for Class I.) 

M. CONSTRUCTION DETAILS - Submit schematic or other appropriate drawings of the surface and subsurface 

construction details of the well. 

N. CHANGES IN INJECTED FLUID - Discuss expected changes in pressure, native fluid displacement, and direction of 

movement of injection fluid. (Class III wells only.) 

O. PLANS FOR WELL FAILURES - Outline contingency plans (proposed plans, if any, for Class II) to cope with all 

shut-ins or wells failures, so as to prevent migration of fluids into any USDW. 

P. MONITORING PROGRAM - Discuss the planned monitoring program. This should be thorough, including maps 

showing the number and location ofmonitoring wells as appropriate and discussion ofmonitoring devices,sampling 

frequency, and parameters measured. If a manifold monitoring program is utilized, pursuant to §146.23(b)(5), 

describe the program and compare it to individual well monitoring. 

Q. PLUGGING AND ABANDONMENT PLAN - Submit a plan for plugging and abandonment of the well including: (1) 

describe the type, number, and placement (including the elevation of the top and bottom) of plugs to be used; (2) 

describe the type, grade, and quantity of cement to be used; and (3) describe the method to be used to place plugs, 

including the method used to place the 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 6 
R. NECESSARY RESOURCES - Submit evidence such as a surety bond or financial statement to verify that the 

resources necessary to close, plug or abandon the well are available. 

S. AQUIFEREXEMPTIONS - If an aquifer exemption is requested,submit data necessary to demonstrate that theaquifer 

meets the followingcriteria:(1) does notserve 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 reasonablyexpected to supply a public water system. Data to demonstrate that the aquifer is 

expected to be mineral or hydrocarbon production, such as general description of the mining zone, analysis of the 

amenability of the mining zone to the proposed method, and time table for proposed development must also be 

included. For additional information on aquifer exemptions, see 40 CFR Sections 144.7 and 146.04. 

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

PSD, RCRA, etc. 

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

EPA Form 7520-6 Page 6 of 6 
OMB 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) 

Section ____ Township ____ Range ____

I am aware that there are 

EPA Form 7520-7 (Rev. 12-11) 
PAPERWORK REDUCTION ACT 

The public reportingand record keeping burden forthis collection ofinformation is estimated to average 5 hours per response. 

Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or 

provide information to or for a Federal Agency. This includes the time needed to review instructions; develop, acquire, install, 

and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and 

maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously 

applicable instructions and requirements; train personnel to be able to respond to the collection of information; search data 

sources;complete and review the collection ofinformation;and,transmitor otherwisedisclosethe information.An agencymay 

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. 

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) Reverse 
OMB 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 25 

hours per quarter for operators of Class I hazardous wells, 16 hours per quarter for operators of Class I nonhazardous wells, and 30 hours per quarter for operators of Class III wells. 

Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, 

or disclose or provide information to or for a Federal Agency. This includes the time needed to review 

instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, 

validating, and verifying information, processing and maintaining information, and disclosing and providing 

information; adjust the existing ways to comply with any previously applicable instructions and requirements; 

train personnel to be able to respond to the collection of information; search data sources; complete and 

review the collection of information; and, transmit or otherwise disclose the information. An agency may not 

conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays 

a currently valid OMB control number. Send comments on the Agency’s need for this information, the 

accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, 

including the use of automated collection techniques to Director, Collection Strategies Division, U.S. 

Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include 

the OMB control number in any correspondence. Do not send the completed forms to this address. 

EPA Form 7520-8 Reverse 
OMB No. 2040-0042 Approval Expires 11/30/2014

United States Environmental Protection Agency 

Washington, DC 20460 

Completion Form For Injection Wells 

Administrative Information 

1. Permittee 

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

2. Operator 

Address (Street, City, State and ZIP Code) 

3. Facility Name 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 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 StrategiesDivision, 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 Stratigraphy 

A. 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 Reverse 
OMB 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 Wt/Ft - Grade - New or Used Depth Sacks Class Depth 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. 

Section ____ Township ____ Range ____

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 to or for a Federal Agency. This includes the time needed to review 

instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, 

validating, and verifying information, processing and maintaining information, and disclosing and providing 

information; adjust the existing ways to comply with any previously applicable instructions and requirements; 

train personnel to be able to respond to the collection of information; search data sources; complete and review 

the collection of information; and, transmit or otherwise disclose the information. An agency may not conduct 

or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently 

valid OMB control number. Send comments on the Agency’s need for this information, the accuracy of the 

provided burden estimates, and any suggested methods for minimizing respondent burden, including the use 

of automated collection techniques to Director, Collection Strategies Division, U.S. Environmental Protection 

Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include the OMB control number in 

any correspondence. Do not send the completed forms to this address. 

EPA Form 7520-10 Reverse 
OMB No. 2040-0042 Approval Expires 11/30/2014

United States Environmental Protection Agency 

Washington, DC 20460 

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 

Section ____ Township ____ Range ____

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 estimated to average 30 hours per quarter.

Burden means the total time, effort, or financial resource expended by persons to generate, maintain, retain, or disclose or provide 

information to or for a Federal Agency. This includes the time needed to review instructions; develop, acquire, install, and utilize 

technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining 

information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable 

instructions and requirements; train personnel to be able to respond to the collection of information; search data sources; complete 

and review the collection of information; and, transmit or otherwise disclose the information. An agency may not conduct or sponsor, 

and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. 

Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods 

for minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies Division, 

U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number

in any correspondence. Do not send the completed forms to this address. 

EPA Form 7520-11 Reverse 
OMB No. 2040-0042 Approval Expires 11/30/2014

United States Environmental Protection Agency 

Washington, DC 20460 

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 

Size Depth Sacks Type From To Treatment Record

WELL CASING RECORD -- AFTER REWORK (Indicate Additions and Changes Only) 

Casing Cement Perforations Acid or Fracture 

Size Depth Sacks Type From To Treatment Record

Section ____ Township ____ Range ____

I am aware that there are significant penalties for submitting false information, including the 

(Ref. 40 CFR 144.32) 

EPA Form 7520-12 (Rev. 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 annually. Burden means the total time, effort, or financial resource expended by persons to generate, maintain, 

retain, or disclose or provide information to or for a Federal Agency. This includes the time needed to review 

instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and 

verifying information, processing and maintaining information, and disclosing and providing information; adjust the 

existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to 

respond to the collection of information; search data sources; complete and review the collection of information; and, 

transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to 

respond to, a collection of information unless it displays a currently valid OMB control number. Send comments on the 

Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for 

minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies 

Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include 

the OMB control number in any correspondence. Do not send the completed forms to this address. 

EPA Form 7520-12 Reverse 
OMB No. 2040-0042 Approval Expires 11/30/2014

United States Environmental Protection Agency 

Washington, DC 20460 

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. 

TYPE OF AUTHORIZATION WELL ACTIVITY

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) 

To From To 

Estimated Cost to Plug Wells 

Section ____ Township ____ Range ____

I am aware that there are significant penalties for submitting false information, including the 

(Ref. 40 CFR 144.32) 

EPA Form 7520-14 (Rev. 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 Reverse 
Type or print all information. See reverse for instructions. OMB No. 2040-0042 Approval Expires 11/30/2014

(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 (Year, Month, Day) 2. FACILITY ID NUMBER

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 B. STREET ADDRESS/ROUTE NUMBER D. LONGITUDE

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

20460, and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503.

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 Agency

UIC Federal Reporting System

Class V Well Pre-Closure Notification Form

1. Name of facility:

Address of facility:

City/Town: State: Zip Code:

County: Location: Lat./Long.:

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):

Drywell Septic tank Cesspool

Improved sinkhole Drainfield/leachfield Other

5. Type of discharge:

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

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

Sample fluids/sediments Clean out well

Appropiate disposal of remaining fluids/sediments Install permanent plug

Remove well & any contaminated soil Conversion to other well type

Other (describe):

9. Proposed date of well closure:

10.Name of preparer: Date:

Certification

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

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

Type or print all information. See reverse for instructions Form Approved 12/99 OMB No. 2040-0214

EPA Form 7520-17
INSTRUCTIONS FOR EPA FORM 7520-17

This form contains the minimum information that you must provide your UIC Program Director if you intend to close your Class V well. This form

will be used exclusively where the EPA administers the UIC Program: AK, AS, AZ, CA, CO, DC, DE, HI, IA, IN, KY, MI, MN, MT, NY, PA, SD, TN, VA, VI,

and on all Tribal Lands. If you are located in a different State or jurisdiction, ask the agency that administers the UIC Program in your State for

the appropriate form.

If you are closing two or more Class V wells that are of similar construction at your facility (two dry wells, for example) you may use one form. If

you are closing Class V wells of different construction (a septic system and a dry well, for example) use one form per construction type.

The numbers below correspond to the numbers on the form.

1. Supply the name and street address of the facility where the Class V well(s) is located. Include the City/Town, State (U.S. Postal Service

abbreviation) and Zip Code. If there is no street address for the Class V well, provide the route number or locate the well(s) on a map and

attach it to this form. Under "Location," provide the Latitude/Longitude of the well, if available.

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 cement

plug placed in the service bay drain and the pipe leading to the washroom connection, and the septic tank/drainfield remains open for septic use only. In this example, the motor vehicle waste disposal well is being converted to another well type (a large capacity septic system).

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 respondent.

Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide

information to or for a Federal agency. This includes the time needed to review instructions, develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and

disclosing and providing information, adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of

information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required

to respond to, a collection of information unless it displays a currently valid OMB control number.

Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including thorough the use of automated collection techniques to the Director, Regulatory

information Division, U.S. Environmental Protection Agency (2137), 401 M. Street, S.W., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA Form 7520-17