STATE OF TENNESSEE 

DEPARTMENT OF ENVIRONMENT AND CONSERVATION 

WATER SUPPLY 

6th Floor, 401 Church Street 

Nashville, Tennessee 37243-1549 

 (615) 532-0191 

APPLICATION FOR AUTHORIZATION TO OPERATE A CLASS V UNDERGROUND 

INJECTION WELL OR STORM WATER DISCHARGE TO THE SUBSURFACE 

 

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: 

 Class V Underground Injection Well 

 Discharge of Storm Water into the Subsurface

Part A - General Information

1. Site or Facility Name 

 Street or Highway Address 

City Zip Code

County Telephone ( ) 

2. Describe the activities conducted by the applicant which require it to obtain a 

Class V permit authorization: 

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3. 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:

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

 Individual or Firm Name 

 Street or RFD 

City State

Zip Code Telephone ( ) 

5. Type of Business: Federal State Public 

Private Other 

6. Nature of Business: 

7. List up to four standard industrial codes (SIC) which best reflect the principal 

products or services provided by the facility: 

a. 

b. 

c. 

d. 

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8. Name and address of legal contact or person responsible for the operation of the 

Class V injection well or facility: 

Name 

 Street or RFD 

 P.O. Box 

City State

Zip Code Telephone ( ) 

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

10. Permit Status: _____a. new well or facility 

 _____b. modification of existing well or facility 

 _____c. reapplication for previously permitted well or facility 

11. List all other permits or construction approvals received or applied for under any 

of the following programs: 

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. Nonattainment area program under federal or state law 

f. National Emission Standards for Hazardous Pollutants (NESHAPS) 

preconstruction approval under federal or state law 

g. Ocean dumping permits under the Marine Protection Research and 

 Sanctuaries Act 

h. Dredge and fill permits under Section 404 of the Clean Water Act, 33 

 U.S.C. 1344 

i. Comprehensive Environmental Response, Compensation and Liability Act 

(Federal Superfund) or Tennessee Hazardous Waste Management Act 

 (Tennessee Superfund) 

j. UST program under federal or state law 

k. Groundwater Protection permits from Tennessee Division of Ground 

 Water Protection 

l. Other relevant environmental permits 

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Permit No. Type Date Issued

Part B - Facility Description

1. Nature, type or purpose of injection well: 

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

associated structures (attach additional information or diagrams, if necessary): 

3. Depth of injection zone: feet below ground level 

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4. Operating status of well or facility: proposed active 

inactive abandoned 

5. Date injection began (if not in operation, projected date of beginning)

If inactive or abandoned well, approximate date injection ceased

6. For previously active facilities, give history of injection or operation: 

7. Mode of operation: __________ continuous _________ intermittent 

8. Volume of injected fluid: gallons or cubic yards 

per day per month per year 

9. Nature of injected fluid, including physical, chemical, biological and/or 

radiological properties: 

10. Origin of injected fluid: 

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11. Description of treatment of fluid prior to injection: 

12. Type of injection: pump gravity other 

 Description of pump(s): 

13. Operating parameters of injection well: 

 a. fluid flow gpm

 b. fluid pressure psig 

 c. fluid temperature Celsius 

 d. other significant operating information (attach additional information or 

diagrams, if necessary): 

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Part C - Description of Area of Review

The area of review (AOR) for each authorized or permitted Class V 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 groundwaters in the AOR. 

3. 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. 

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. 

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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, 

vice-president, or equivalent person) who performs policy or decision making functions; 

or

2. The manager of one or more manufacturing, production, or operating facilities employing 

more than 250 persons or having gross annual sales or expenditures exceeding $25 

million if authority to sign documents has been assigned or delegated to the manager in 

accordance with operating procedures; or 

3. For a partnership, by a general partner or the proprietor; or 

4. 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. 

5. 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

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Attachments

1. USGS topographic quadrangle map showing the location of the Class V 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 diagram of the injection well 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 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. Construction diagrams depicting erosion and sediment controls. 

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