STATE OF TENNESSEE 

DEPARTMENT OF ENVIRONMENT AND CONSERVATION 

WATER SUPPLY 

9 th Floor, 401 Church Street 

Nashville, Tennessee 37243-1549 

 (615) 532-0191 

APPLICATION FOR AUTHORIZATION TO OPERATE A CLASS I UNDERGROUND

INJECTION WELL 

 

In accordance with the provisions of Tennessee Code Annotated Section 69-3-105 and 

Regulations of the Tennessee Water Quality Control Board, application is hereby made to

operate: 

Part A - General Information

1. Site or Facility Name 

 Street or Highway Address 

City Zip Code

 County Telephone ( )

2. Describe the activities conducted by the applicant which require it to obtain a Class I

permit authorization (attach additional information or diagrams, if necessary): 

3. USGS topographic coordinates of the injection well or facility location (if multiple wells 

are at the same site, then give principal site latitude and longitude, and average 

elevation): 

 Quadrangle Name 

Latitude o ’ ” North 

 Longitude o ’ ” West 

Ground elevation at well location:

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4. Name and address of owner of injection well or facility:

 Individual or Firm Name 

 Street or RFD 

City State

Zip Code Telephone ( ) 

5. Type of Business: Federal State Public 

 Private Other 

6. Nature of Business (attach additional information or diagrams, if necessary): 

7. List up to four standard industrial codes (SIC) which best reflect the principal products or

services provided by the facility: 

a. 

b. 

c. 

d. 

8. Name and address of legal contact or person responsible for the operation of the Class II

injection well or facility: 

Name 

 Street or RFD 

 P.O. Box 

City State

Zip Code Telephone ( ) 

9. Is the facility located on Indian Lands? Yes No 

10. Permit Status: _____a. new well or facility

 _____b. modification of existing well or facility

 _____c. reapplication for previously permitted well or facility

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11. List all other permits or construction approvals received or applied for under any of the

following programs (attach additional information or diagrams, if necessary): 

a. Hazardous waste management program under federal or state law 

b. UIC program under federal or state law 

c. NPDES program under federal or state law 

d. Prevention of Significant Deterioration (PSD) program under federal or state law 

e. Nonattainment area program under federal or state law 

f. National Emission Standards for Hazardous Pollutants (NESHAPS) 

preconstruction approval under federal or state law 

g. Ocean dumping permits under the Marine Protection Research and 

 Sanctuaries Act 

h. Dredge and fill permits under Section 404 of the Clean Water Act, 33 U.S.C. 

 1344 

i. Comprehensive Environmental Response, Compensation and Liability Act 

(Federal Superfund) or Tennessee Hazardous Waste Management Act

 (Tennessee Superfund) 

j. UST program under federal or state law 

k. Groundwater Protection permits from Tennessee Division of Ground Water 

 Protection 

l. Other relevant environmental permits 

Permit No. Type Date Issued

Part B - Facility Description

1. Nature, type or purpose of injection well (attach additional information or diagrams, if 

necessary): 

2. Description of injection well or facility, including monitoring wells and other associated

structures (attach additional information or diagrams, if necessary): 

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3. Depth of injection zone: feet below ground level 

4. Formation name: 

5. Operating status of well or facility: proposed active 

 inactive abandoned 

6. Date injection began (if not in operation, projected date of beginning)

If inactive or abandoned well, approximate date injection ceased

7. For previously active facilities, give history of injection or operation (attach additional 

information or diagrams, if necessary): 

8. Mode of operation: __________ continuous _________ intermittent 

9. Volume of injected fluid: gallons or cubic yards 

 per day per month per year 

10. Nature of injected fluid, including physical, chemical, biological and/or radiological 

properties (attach additional information or diagrams, if necessary): 

11. Origin of injected fluid (attach additional information or diagrams, if necessary): 

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12. Description of treatment of fluid prior to injection (attach additional information or 

diagrams, if necessary): 

13. Type of injection: pump gravity other 

 Description of pump(s) (attach additional information or diagrams, if necessary): 

14. Operating parameters of injection well: 

 a. fluid flow gpm

 b. fluid pressure psig 

 c. fluid temperature Celsius 

 d. other significant operating information (attach additional information or 

diagrams, if necessary): 

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Part C - Description of Area of Review

The area of review (AOR) for each authorized or permitted Class II injection well shall, unless 

otherwise specified by the Department, consist of the area lying within and below a one mile

radius of the injection well pump site or facility, and shall include, but not be limited to surface 

geographic features, subsurface geology, and demographic and cultural features within the area.

Attach to this part of the application a complete characterization of the AOR, including the 

following: 

1. Description of all past and present uses of groundwater within the AOR, as documented

by public record. 

2. Description of the groundwater hydrology within the AOR, including characteristics of 

all subsurface aquifers, presence or absence of solution development features, general

direction of groundwater movement, and chemical characteristics of the groundwater in

the AOR. 

3. Description of the population and cultural development within the AOR, including the

number of persons living within one mile of the well or facility, land uses within the 

AOR, and the existence of any community, state, regional or national parks, wildlife 

refuges, natural or wilderness areas, recreational or other public-use areas, or any other

environmentally sensitive features within the area of review. 

4. Identify all sources of publicly-supplied drinking water for persons living or working 

within the AOR. 

5. Identify any single or multi-family residences, churches, schools, businesses or other

inhabited structures within the AOR which do not have access to a public drinking water 

supply system. 

6. If groundwater is used for drinking water within the area of review, then identify and 

locate on Attachment 1, all groundwater withdrawal points within the AOR which supply 

public or private drinking water systems. 

7. Identify any surface water bodies or features within the area of review which may be

impacted by groundwater discharge to surface waters. 

8. Identify any surface water intake which supplies a public water distribution system and is 

located within the AOR or within three miles topographically downgradient from the well 

or facility. If any such intake(s) exist, then locate on Attachment 1. 

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Part D - Signature and Certification

This application should be signed by a person having responsibility for the operation of the injection well 

or facility as follows: 

1. For a corporation, by a responsible corporate officer (i.e., president, secretary, treasurer,

vice-president, or equivalent person) who performs policy or decision making functions;

or

2. For a partnership, by a general partner or the proprietor; or 

3. By a duly authorized representative (a duly authorized representative may be either a

named individual or any individual occupying a named position) only if: 

 a. The authorization is made in writing by a person described in (1), (2), or (3) 

above; 

 b. The authorization specifies either an individual or a position having

responsibility for the overall operation of the regulated facility or activity, such

as the position of plant manager, operator of a well or well field, superintendent,

or position of equivalent responsibility, or 

 c. For municipality, state, federal, or other public agency by either a principal 

executive officer or ranking elected official. 

4. The owner of the property or facility on which the injection well is located. 

I certify under penalty of law I have personally examined and am familiar with the information 

submitted in the attached document; and based on my inquiry of those individuals immediately 

responsible for obtaining the information, I believe the submitted information is true, accurate, 

and complete. I am aware there are significant penalties for submitting false information, 

including the possibility of fine or imprisonment. 

 

Name & Title (print or type) License No. 

 

Signature Date

 

Name & Title (print or type) License No. 

 

Signature Date

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Attachments

1. USGS topographic quadrangle map showing the location of the Class I injection well or 

facility and a one-mile radius area surrounding the well or facility.

2. USGS geologic quadrangle or regional geologic map showing the subsurface structure in 

the area of the well or facility, from the surface to the injection zone. 

3. Schematic diagrams of the injection well(s) showing construction details and materials of 

the injection well. 

4. Chemical analysis data of injection fluid, if required. 

5. Process description of the treatment or other process which is the source of the injection 

fluid, if required. 

6. Procedure for operation and maintenance of the injection well or facility, if required. 

7. Geologic/hydrogeologic and construction information collected during the planning,

construction and design phases of the facility and injection well. 

8. Blueprints from the facility showing the injection well and portions of the facility, which 

will or may contribute injectate to the injection well, including storm runoff waters. 

9. Documentation of proper bond amount. 

10. Documentation of financial surety. 

11. Completed closure (Plugging and Abandonment) plan. This is a separate application that 

must be on file before injection is allowed to continue.

12. Documentation of previous Mechanical Integrity Test (MIT). 

13. All information required in the Class II guidance document. 

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