STATE OF TENNESSEE 

DEPARTMENT OF ENVIRONMENT AND CONSERVATION

DIVISION OF WATER SUPPLY 

9th Floor, 401 Church Street 

Nashville, Tennessee 37243-1549 

 (615) 532-0191 

APPLICATION FOR AUTHORIZATION TO OPERATE A CLASS II 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 State Zip Code

County Telephone ( )

2. 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 

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

 Individual or Firm Name 

 Street or RFD 

City State

 Zip Code Telephone ( )

4. Permit Status: a. new well or facility 

 b. modification of existing well or facility 

 c. reapplication for previously permitted well or facility 

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

programs:

a. UIC program under federal or state law 

b. NPDES program under federal or state law 

c. Nonattainment area program under federal or state law 

d. Other relevant environmental permits

 Permit No. Type Date Issued

CN-pending RDA pending

1
Part B - Facility Description

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

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

(attach information or diagrams). 

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 information or

diagrams). 

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 information or diagrams). 

11. Origin of injected fluid (attach information or diagrams). 

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

13. Type of injection: pump gravity other 

 Description of pump(s) (attach information or diagrams). 

14. Operating parameters of injection well: 

 a. fluid flow gpm

 b. fluid pressure psig

 c. fluid temperature Celsius 

d. other significant operating information (attach information or diagrams). 

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. 

2. 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. 

2

CN-pending RDA pending
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. 

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, vicepresident 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

CN-pending RDA pending

3
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 guidance document. 

CN-pending RDA pending

4