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. OMB No. 2040-0042 Form Expires 11/30/2014 United States Environmental Protection Agency

Office of Grou nd Wate r 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 Determin
ation 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C Number of Wells in Area Permits (See B above) New Wells Existing Wells Permit Not Issued D Number of Permits Denied/Withdrawn (after complete technical review)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EPA Form 7520-1 (Rev. 12-11) Previous edition is obsolete.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 fiscal year, and includes activities from October 1 – Septembe r 30. All fields should contain a value. Do not leave blank fields. Enter 0 if there are no wells affected or no activities that occurred pertaining to the information requested. Enter NA if the field or section is not applicable to the submitter (e.g., the well type is not overseen by the submitter). Enter U if the information is unknown or not captured; fields designated as U require explanation. 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, including incomplete applications, for individual and area permits. Include all applicati ons regardless of whether they are for “New Wells” or “Existing Wells.” A “New Well” is any well that began operation after the effective date of the State (or EPA) Unde rground 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. A “New Well Field” has only “New Wells” or a combination of “New Wells” and “Existing Wells.” An “Existing Well Field” contains only “Exi sting Wells.”

Section VI. Permit Determination Permit Determinations include the approval, withdraw al, or denial of UIC permit requests/actions such as: applications for permits, major modifications to issued pe rmits, revocation and reissuance of permits, or termination of permits for cause. A complete permit determination includes a thorough technical evaluation of the request, public notification or revi ew before issuance, and a final decision document signed by the regulating authority. Item A: For each well class, 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. 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 federa l fiscal year to date. The denial of a permit or major modificatio n should be included as a permit determination only after there has been a complete technical review. Item E: For each well class, ente r the number of major modifications approved this federal fiscal year to date. An approved major modification requires a comple te technical review, public notification or review, and a final decision document signed by the regulating authority.

Section VII. Permit File Review A complete technical review of a rule authorized Class II well record may be conducted to dete rmine whether the well is in compliance with UIC regulatory re quirements in lieu of a permit determination. The well record (or file) review may include an evaluation of siting reports, wells in the area of review, construction, operating, monitori ng or other reports. These Class II wells should be routinely reviewed at least once every five years during the life of the well. Wells Reviewed: For rule authorized (exi sting) 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) and that received corrective action.
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 penetr ating the injection zone in the AoR that has been properly or improperly plugged and/or abandoned. “Other” includes any producing we ll, operable injection well, dry hole, exploratory well, etc., that penetrates the injection zone in the AoR. Corrective Action is required for those wells that penetrate the injection zone in the AoR that are improperly sealed, completed, or abandoned. Item B: For each well class, enter the number of “Abandoned” and “Other” wells in the AoR that have required corrective action for each permit application or file reviewed this federal fiscal year to date. Item C: For each well class, enter the number of wells in the AoR which have received corrective action (be specific) for all permit applications or files that have b een reviewed this year to date. Paperwork Reduction Act Notice The public reporting and record keeping burden for this collection of information is es timated to average 4.5 hours per year. Burden means the total time, effort, or financial resource expended by persons to generate, ma intain, 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., Washingt on, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.
EPA Form 7520-1 (11-15) Revised