STATE OF TE NNESSEE

D E P A RT M E NT O F EN VIR O N M EN T A ND CO N S ER V A TIO N

DIVISIO N O F W A TE R SUPPLY

9th Floor, 4 01 C hurch Street

Nashville, Tennessee 37243-154 9

( 615) 532- 0191

APPLICATIO N FOR AUTHORI Z A TION T O OPERA TE A CLASS I I UNDERGROUN D INJECTION WELL

In accordance with the provis ions of Tennes see Code Annotated Section 69-3-105 and Regulations of th e

Tenn essee Wat e r Qu ality Co ntro l Bo ard

, a pplicatio n is h e reb y m a d e to op erate:



### Part A

- G e neral Information

1

. Site o r Facility Nam e

Street or Highway Address

C i t y S t a t e Zi p C o de

C o u n t y Tele phone ( )

2

. USGS topo grap h i c coo r d i n a t e s of th e i n j ect io n we ll or faci lity lo catio n (if m u lt ip le wells are at th e

sam e si te, th en g i v e prin ci p a l site latitu d e and long itu d e , and av erag e elevatio n ) :

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

Latitu d e o ’ ” North

Lo ngi t u d e o ’ ” W e st

Gro und elev atio n at well l o catio n

3

. Nam e an d ad dress of o w n e r o f in

j ecti o n well o r facility:

In di vi dual or F i rm Nam e

S t r e e t o r R F D

C i t y S t a t e

Zi p C o d e Tele phone ( )

4. Perm it Status: a. n e w well or facility

b

. m o d i fication of ex istin g well o r facility

c. reapp licatio n for p r ev iou s l y p e rm itted well o r facility

5. List all other perm it s or construction approvals received or applied for under a n y of t h e following

pr o g ram s :

a. UIC pr o g ram u nde r fede ral or st at e l a w

b. NP DES p r o g ra m under fe dera l or st at e l a w

c. No nat t a i n m e nt area pr o g ram un de r fe de ral o r st at e l a w

d. Ot he r rel e vant envi ro nm ent a l perm i t s

Perm it No

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

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### Part B

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

1

. Nature, typ e or pu rpo s e o f injectio n well (attach info rm atio n o r d i ag ram s ).

2

. Descri p tio n o f in j ection well o r facility, in clu d i n g m o n ito ri n g wells and o t h e r asso ciated stru ctures

(attach in f o rm ation or dia g ra m s ).

3. Dept h of i n

ject i on z o ne: feet bel o w gr o u n d l e vel



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

5

. Op erating status of well or facilit y : pr opo sed active

in activ e aba n doned

6

. Date inj ection b e g a n (if no t in op eration

, projected d a te of beg i nn ing )

If i n act i v e or a

b an d one d wel l

, ap pr o x im a t e date injection ce ased

7

. Fo r prev i o usly activ e faciliti es, g i v e h i story o f inj ection o r o p e ration (attach in formatio n o r

diag ram s ).

8

. Mo d e of o p e r a tio n :

__ ___ ___ __ con tin uou s

__ ___ ___ _ in ter m it ten t

9. Vol u m e of i n je ct ed fl ui d: gal l o ns or cu b i c yard s

pe r day pe r m ont h pe r year

10

. Nat u re o f i n je ct ed fl ui d, i n c l udi n g phy si ca l

, chem i cal , biol o g i cal an d/ o r ra di ol ogi cal pr o p ert i e s

(attach in f o rm ation or dia g ra m s ).

11

. Ori g i n of i n

jec t ed fl ui d (at t ach i n f o rm at i on or di a g ram s ).

12

. Descri pt i o n o f t r eatm e nt of fl ui d p r i o r t o i n j ect i on (at t ach i n f o rm at i on o r di ag ram s ).

13

. Ty pe of i n je ct i on: pum p grav ity ot he r

Descri pt i o n o f pum p(s ) (at t a c h i n f o rm at i on or di a g ram s ).

1 4

. Op erating p a rameters o f inj e ctio n well:

a. fluid flo w gp m

b. fl ui d p r ess u re psi g

c. fluid tem p erature Celsiu s

d

. o t h e r sign ifican t op eratin g inform at io n (attach info rm atio n or d i ag ram s ).



### 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 re view (AOR) for eac h a u t h or i zed o r pe rm it ted C l ass II i n j ect i on wel l s h al l

, unl ess ot he rwi s e

sp ecified b y the Dep a rtm e n t

, co nsist o f th e area lyin g within and b e l o w a o n e m ile rad i u s of th e inj ect io n

well pu m p site or facility, an d sh all in clud e, bu t no t b e limited to surface g e og ra p h i c featu r es, sub s urface

geol ogy , a n d dem ogra phi c a nd c u l t u ral fea t ures wi t h i n t h e area. At t ach t o t h i s pa rt o f t h e ap pl i cat i on a

co m p lete ch aracterizatio n o f th e AOR, in cl ud ing th e fo llowin g :

1

. D e scr i p tio n o f all p a st and presen t u s es of gr oun dw ater w i t h in t h e AO R, as do cu m e n t ed b y pu b lic

record.

2

. D e scr i p tio n of th e g r ou ndwater h y d r o l ogy w ith in t h e A O R , in cl u d i n g ch ar acter istics o f all

sub s u rface a q u i fers, p r ese n ce o r a

b se nce of sol u t i o n de ve l opm ent feat u r es, gene ral di r ect i on of

groundwater movem e nt, and c h em ical charact eristics o f t

h e g r ou nd water in th e AOR

.

2

. Descri p tio n o f th e po pu latio n an d cu ltu ral d e v e lop m en t wit h in th e AOR , in clud ing th e nu m b er o f

p e rson s liv ing with in on e m i l e o f th e well or f acility, lan d u s es with in t h e AOR , an d t h e ex isten c e

of a n y c o m m u n i t y , st at e, re gi onal or nat i o n a l par k s, wild li fe refug e s, natu ral o r wild erness areas,

recreation a l o r o t h e r p u b lic-use areas, or any o t h e r env i ron m en tally sen s itiv e featu r es with in th e

area of re view.

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. Id en tify all sou r ces of pu b licly-su p p lied drin k i n g water for p e rson s liv ing o r wo rk ing with in t h e

AOR.

5

. Id en tify an y si n g l e o r m u lti-fa m i l y resid e n c es, chu r ch es, sch o o l s, bu sin e sses or o t h e r in h a b ited

structures within the AOR which do not ha ve access to a public drinking water supply syste m

.

6

. If gro und water is u s ed fo r drin k i ng water with in the are a of re view, th en identify and locate on

Attachm e nt 1, all groundwater w ithd r awal po in ts with i n the AOR wh ich su pp ly pu b lic o r p r iv ate

dri nki ng wat e r sy st em s.

7. Ide n tify any s u rface water bodies or feat ure s within t h e area of re view which m a y be im pacted by

groundwater discharge t o s u rface waters

.

8. Ide n tify a n y surface water int a ke whic h s upplies a public water distribution system and is located

with in t h e AOR o r with i n t h ree m iles to p o g r aph i cally d o wng r ad ien t from th e well o r facility. If

an y su ch in take(s) ex ist, t h en locate on Attachm e nt 1.



### 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 co rp o r at i on, by a resp ons i b le corporate officer (i.e ., pre s ide n t, secretary, treasurer, vicepresi d ent o r e q ui val e nt pe rs on ) w h o per f o rm s p o l i c y or deci si on m a ki ng f u nct i o n s ; o r

2. For a part ners h i p, by a gene ra l part ner o r t h e p r o p ri et o r ; or

3. By a duly authorized repres en tativ e (a du l y au th orized rep r esen tativ e may b e eith er a n a m e d

in d i v i d u a l or an y ind i v i du al occ u p y ing a n a med po sitio n) o n l y if:

a. Th e au tho r izati o n is m a d e in writing b y a p e rson d e scrib e d in (1 ), (2) o r (3) ab ov e;

b

. Th e au t h orizatio n sp ecifies eith er an ind i v i d u al o r a p o s ition h a v i ng respo n sib ility fo r th e

o v e rall o p e ratio n o f th e regu lated facility o r activ ity, su ch as th e positio n o f p l an t

man a g e r, op erato r of a well o r well field, su p e rin t en d e n t , o r p o sitio n o f equ i v a len t

respon sib ility; o r

c. Fo r m u n i cip a lity, state, fed e ral, or o t h e r pub lic ag en cy by eith er a p r i n cip a l ex ecu tive

of

fi cer or ra n k i n g elected offi cial.

4

. Th e own e r o f th e p r op erty or facility o n wh i c h th e inj ection well is lo cated

.

I certify und er p e n a lty of law I h a v e p e rson ally ex am in e d and am fa m i liar with th e inform at io n su bmit ted

i n t h e at t ache d d o cum e nt ; and base d o n m y i nqui ry of t hose i n di vi d u al s im m e di atel y respo n si bl e for

o b t ain i n g th e i n fo rm atio n

, I believ e th e submit ted in fo rm a tion is true, ac curate, and c o m p le te. I am aware

th ere are significan t p e n a lties for sub m i t tin g false in fo rm atio n

, in clu d i n g th e p o ssib ility o f fin e or

im pri s onm 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 ation required i n the gui dance document.

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