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Number of Permits Denied/Withdrawn 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EPA Form 7520-1 (Rev. 12-11) Previous edition is obsolete.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 fiscal year, and includes 

activities from October 1 – September 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 applications 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) 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. 

A “New Well Field” has only “New Wells” or a combination of 

“New Wells” and “Existing Wells.” An “Existing Well Field” 

contains only “Existing Wells.” 

Section VI. Permit Determination

Permit Determinations include the approval, withdrawal, 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. 

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 a 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. 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 (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) 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 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 (11-15) Revised