STATE OF TE NNESSEE

DEPA RTME NT OF ENVI RO NMEN T A ND CO NSER VATION

WATER SUP P LY

9 th Floor, 4 01 C hurch Street

Nashville, Tennessee 37243-154 9

( 615) 532- 0191

APPLI CATI O N FO R AU THORIZ ATI O N T O OPE RATE A CLA SS I U NDE R G RO U N D

INJ E CTION WELL

In accordance with the provisions of Tenn essee Code Annotated Secti on 69-3- 105 and

Regulations of the Tennessee W a ter Quality Cont rol Board, application is hereby made to

operate:



### Part A

- G e n e r a l I n f o rmation

1. Site or F a c i l i t y Nam e

Street or Highway Addres s

C i t y Zip Code

Count y Telephone ( )

2. Describe the activities conducted by t h e a pplicant which require it to obtain a Class I

per m it authorization (attach additional in form ation or diagrams, if necessary ) :

3. USGS topogr aphic coordinates of the inj ec tion well or facility location (if m u ltiple wells

are at the s a m e site, then give principa l site lat itude and longitude, and averag e

elevation):

Q u a d r a n g l e N a m e

L a t i t u d e o ’ ” North

Longitu d e o ’ ” West

Ground elevation at well lo c a t i o n :

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14. Name and address of owner of injection well or facilit y :

Individ u al or Firm N a m e

S t r e e t o r R F D

C i t y S t a t e

Z i p C o d e Telephone ( )

5. T y p e o f B u s i n e s s : F e d e r a l S t a t e Public

Private Other

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

7. List up to fou r standard industrial codes (S IC) which best reflect the principal products or

services provided by the facility :

a

. b

.

c

. d

.

8. Name and address of legal contact or pe rs on responsible for the operation of the Class I I

injection well or facility:

N a m e

S t r e e t o r R F D

P

. O

. B o x

C i t y S t a t e

Z i p Code Telephone ( )

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

10. Perm it Status: ___ __a. ne w well or facilit y _____b. m odificati on of existing well or facility

_____c. reapplicat i on for previously perm itted well or facility

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211. List all other perm its or c onstruction appr ovals received or applie d for under any of the

following progra m s (att ach additional information or diagra m s , if neces sary ) :

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. Nonattain m e nt area program under federal or state law

f. National Emission Standards for Hazardous Pollutants (NESHAP S)

preconstruction appro v al u nder federal or state law

g. Ocean du mping perm it s under the Marine Protection Research and

Sanctuaries A c t

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

134 4

i. Co m p rehensi v e Environmental Response, Com p ensation and Liabilit y Act

(Federal Su perfund) or Tennessee Hazardous Waste M a nagem e nt Act

(Tennessee Superfund)

j. UST program under federal or state law

k. Groundwater Protection pe r m its fro m Tennessee Division of Ground Water

Protection

l. Other relevan t environm ental perm its

P e r m it No

. T y p e D a t e I s s u e d



### Part B

- F a c i l i t y D e s c r i p t i o n

1. Nature, ty pe or purp o se of injection well (a ttach additional infor m ation or diagram s , if

necess ary ) :

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

structures (att ach additiona l inform ation or diagrams, if necess ary ) :

CN- RDA-2474

33. Depth of inje ction zone: feet below ground level

4. F o r m a t i o n n a m e :

5. Operating status of well or facility : proposed active

inactive abandoned

6. Date injectio n began (if n o t in ope ration

, projected date of beginni n g )

If inactive or abandoned w e ll, approximate date inject i o n c e a s e d

7. For previousl y active facilities, give histor y of injection or operat i on (attach additional

inform ation or diagra m s , if necess ary ) :

8. Mode of o p eration: _

___ _

____ _ conti n uous

___ __ ____ interm ittent

9. Volume of injected fluid: gallons or cubic y a rd s

per da y per m o n t h per y ear

10. Nature of in jected fluid, includin g p h y sical, chem ical, biologic a l and/or rad i ological

properties (attach additiona l inform ation or diagrams, if necess ary ) :

11. Origin of inje cted fluid (attach additiona l inform ation or diagrams, if necess ary ) :

CN- RDA-2474

412. Description o f treatment of fluid pri o r to injection (att ach additiona l inform ation or

diagra m s , if neces sary ) :

13. Type of injec tion: pum p gravit y other

Desc ription of pum p(s) (att ach additiona l inform ation or diagrams, if necess ary ) :

14. Operating param e t e rs of injection well:

a. fluid flow gpm

b. fluid pressure psig

c. fluid tem p erature Celsius

d. other signifi cant operati ng inf o rm ation (attach additional i n form ation or

diagra m s , if neces sary ) :

CN- RDA-2474

5

### Part C

- D e s c r i p t i o n o f A r e a o f R e v i e w

The area of r e view (AOR) for each authorized or pe r m itted Class II injection well shall, unless

otherwise sp ecified by th e Departm e nt, consist of t h e area ly ing within and below a one mil e

radius of the injection wel l pum p site or fac ility , and shall include, but not be limited to surface

geographic features, subsurface geol ogy, and dem ographic and cul t ural features within the ar ea.

Attach to this part of the application a co m p lete characterization of the AOR, including the

following:

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

by public record.

2. Description o f the grou nd water hy drol og y withi n th e AOR, inclu d ing characteristics of

all subsurface aquifers, presenc e or absence of solution development features, general

direction of g r oundwater m ovement, and chem ical characteristics of the grou ndwater in

the AOR.

3. Description o f the populat ion and cultu ral development within th e AOR, inclu d ing the

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

AOR, and the existence o f any community , st ate, regional or n a tional parks, wildlife

refuges, natural or wilder ness ar eas, recrea tional or other public- u se areas, or any ot her

environm entally sensitive features withi n the area of review.

4. Identif y all sources of publicl y -supplie d dr inking w a ter for persons living or working

within the AOR.

5. Identif y any single or m u lti-fam ily residences, churches, schools, businesses or other

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

suppl y s y ste m

.

6. If groun dwater is used for drinki ng w a ter within the area of re view, then identify and

locate on Attach m e nt 1, all groun dwater withdrawal points within the AOR which suppl y public or priv ate drinking water sy stems.

7. Identif y any surface water bodies or features within the area of review which m a y be

i m pacted by groundwater discharge to surface wat e rs

.

8. Identif y any surface wat e r intake which suppli es a public water distr i bution s y stem and is

located within the AOR or within three miles topographically dow ngradient fro m the well

or facility . If any such inta ke(s) exist, then locate on Attach ment 1.

CN- RDA-2474

6

### Part D

- S i g n a t u r e a n d C e r t i f i c a t i o n

Th is ap p lication sh ou l d b e sign ed b y a p e rson h a v i n g respon sib ility for the op eration o f t

h e inj ection well

o r

facility as follo ws:

1. For a corporation, by a responsible corpor ate officer (i.e., president, secret ary

, t r easurer,

vice-president, or equi valent person) w ho perform s polic y or decision m a king functions;

or

2. For a partnership, b y a gen e ral partner or the propriet o r; or

3. By a duly a u thorized representative (a dul y authorized represent a tive may be either a

nam e d indivi dual or any individual occupy ing a named position) only if:

a. The authoriz ation is m a d e in writing by a person describ ed in (1), (2), or (3)

above;

b. The authori zation specifies either an indivi du al or a position havi ng

responsibilit y for the over a ll operation of the regulat ed facility or activit y

, suc h

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

, or position of equivale nt responsibilit y

, or

c. For m unicipality

, state, federal, or ot her publ ic agency by eit h er a principal

executive officer or ranking elected official.

4. The owner of the propert y or facility on which the inj ection well is located.

I certify unde r penalty of l a w I have personally ex a m ined and am familiar with the infor m ation

subm itted in the attached docum ent; and based on m y inquir y of those individuals i mmedi ately

responsible for obtaining the inform ati on, I be lieve the subm itted inform ation is true, accurate,

and com p let e . I am aware there are significant penalties for subm itting false information,

including the possibilit y of fine or im prisonm ent.

Name & Title (print or t y pe ) License No.

S i g n a t u r e D a t e

Name & Title (print or t y pe ) License No.

S i g n a t u r e D a t e

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## Attachments

1. USGS topographic quadrangle m a p sho w ing the location of the Class I injection well or

facility and a one-m ile radius area surro unding the w e ll or facility

.

2. USGS geologic quadrangle or regional geol ogic map showing the subsurface str u cture in

the area of the well or facil ity, fro m the surface to the injection zone.

3. Schem a tic diagram s of the injection well(s ) showing construction de tails and materials of

the injection well.

4. Chem ical analy s is data of i n jection fluid

, if required.

5. Process de scr iption of the treat ment or other process which is the source of the injection

fluid, if req u i r ed.

6. Procedure for operation and m a intenance of the injection well or facility , if requi red.

7. Geologic/h y d r ogeologic and construction inform ation collected during the planning

, construction and design phases of th e facility and inje ction well.

8. Blueprints from the facilit y showing the in jection well and portions of the facil ity, which

will or may c ontribute i n jectate to the injection well, including stor m

runoff waters.

9. Docu m e ntation of proper bond am ount.

10. Docu m e ntation of fi nancial surety

.

11. Co m p leted closure (Pluggi ng and Aban donm ent) plan. This is a s e parate application that

m

u st be on fil e before injec tion is allowed to cont inue.

12. Docu m e ntati on of previous Mechanical Integrity Test (MIT).

13. All inform ati on required in the Class II guidance doc ument.

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