STATE O F TENNESSEE

DEPARTMENT OF ENVIRONMENT AND CONSERVATION

WATER SUPPLY

6th Floor, 401 Church Street

Nashville, Tennessee 37243-1549

( 615) 532- 0191

APPLICATION FOR AUTHORIZ ATION TO OPERATE A CLASS V UNDERGROUND

INJ E CTION WELL OR STORM WATER DISCHARGE TO THE SUBSURFACE

In accordance with the provisions of Tenne ssee Code Annotated Section 69-3-105 and

Regulations of the Tennessee W a ter Quality Control Board, application is hereby m a de

to operate:

Class V Underground Injection Well

Discharge of Storm Water into the Subsurface



### Part A

- G e n e r a l I n f o r m a t i o n

1. Site or Facility Nam e

Street or Highway A d d r e s s

C i t y Z i p C o d e

C o u n t y T e l e p h o n e ( )

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

Class V perm it authorization:

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13. USGS topographic coordinates of the injection well or facility location (if

m

u ltiple wells are at the sam e site, then give principal site latitude and longitude,

and average elevation):

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

L a t i t u d e o ’ ” North

L o n g i t u d e o ’ ” W e st

G r o u n d e l e v a t i o n a t w e l l l o c a t i o n :

4. Nam e and address of owner of injection well or f acility:

Individual or Firm Nam e

S t r e e t o r R F D

C i t y S t a t e

Z i p C o d e T e l e p h o n e ( )

5. T y p e o f B u s i n e s s : F e d e r a l S t a t e Public

P r i v a t e Other

6. Nature of Business:

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

products or services provided by the facility:

a

. b

.

c

. d

.

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28. Nam e and address of legal contact or person responsible for the operation of the

Class V injection well or f acility:

N a m e

S t r e e t o r R F D

P

. O

. B o x

C i t y S t a t e

Z i p C o d e T e l e p h o n e ( )

9. Is the f a c i l i t y l o c a t e d o n I n d i a n L a n d s ? Y e s No

10. Perm it Status: _____a. new well or facility

_____b. m odification of existing well or facility

_____c. reapplication for previously perm itted well or facility

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

of the following program s:

a. Hazardous waste m a nagem e nt 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 Deterior ation (PSD) program under federal or

state law

e. Nonattainm e nt area program under federal or state law

f. National Em ission Standards for Hazardous Pollutants (NESHAPS)

preconstruction approval under federal or state law

g. Ocean dum ping perm its under the Marine Protection Research and

Sanctuaries Act

h. Dredge and fill perm its under Sec tion 404 of the Clean W a ter Act, 33

U.S.C. 1344

i. Com p rehensive Environm ental Response, Com p ensation and Liability Act

(Federal Superfund) or Tennessee Hazardous W a ste Managem e nt Act

(Tennessee Superfund)

j. UST program under federal or state law

k. Groundwater Protection perm its from Tennessee Division of Ground

W a ter Protection

l. Other relevant environm ental perm its

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3P e r m it No

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



### Part B

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

1. Nature, type or purpose of injection well:

2. Description of injection well or f acility, including m onitoring wells and other

associated structures (attach additional inform ation or diagram s , if necessary):

3. D e p t h o f i n j e c t i o n z o n e : feet below ground level

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44. Operating status of well or f a c i l i t y : p r o p o s e d active

i n a c t i v e abandoned

5. Date injection began (if not in ope r a t i o n

, p r o j e c t e d d a t e o f b e g i n n i n g )

If inactive or abandoned well, approxim a t e d a t e i n j e c t i o n c e a s e d

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

7. Mode of operation: __________ continuous _________ interm ittent

8. Volum e o f i n j e c t e d f l u i d : g a l l o n s or cubic yards

p e r d a y per m o n t h per year

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

radiological properties:

10. Origin of injected fluid:

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511. Description of treatm e nt of fluid prior to injection:

12. T y p e o f i n j e c t i o n : pum p g r a v i t y other

Description of pum p(s):

13. Operating param e ters of injection well:

a. fluid flow gpm

b. fluid pressure psig

c. fluid tem p erature Celsius

d. other significant operating inform ation (attach additional inform ation or

diagram s , if necessary):

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### 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 review (AOR) for each authorized or perm itted Class V injection well shall,

unless otherwise specified by the Departm e nt, consist of the area lying within and below

a one m ile radius of the injection well pum p site or f acility, and shall include, but not be

lim ited to surface geographic features, subsurface geology, and dem ographic and cultural

features within the area. Attach to this part of the application a com p lete characterization

of the AOR, including the following:

1. Description of all past and present uses of groundwater within the AOR, as

docum ented by public record.

2. Description of the groundwater hydrology within the AOR, including

characteristics of all subsurface aquife rs, presence or absence of solution

developm ent features, general direction of groundwater m ovem e nt, and chem ical

characteristics of the groundwaters in the AOR.

3. Description of the population and cultural developm ent within the AOR,

including the num ber of persons living within one m ile of the well or f a cility, land

uses within the AOR, and the existence of any com m unity, state, regional or

national parks, wildlif e ref uges, natural or wilderness areas, recreational or other

public-use areas, or any other environm enta lly sensitive f eatures 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 m u lti-fam ily 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 re view, then identify

and locate on Attachm e nt 1, all groundwater withdrawal points within the AOR

which supply public or private drinking water system s.

7. Identify any surface water bodies or features within the area of review which m a y

be im pacted by groundwater discharge to surface waters.

8. Identify any surface water intake whic h supplies a public water distribution

system and is located within the AOR or within three m iles topographically

downgradient f r om the well or f acility. If any such intake(s) exist, then locate on

Attachm e nt 1.

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### 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

This application should be signed by a pers on 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 perform s policy or decision m a king functions;

or

2. The m a nager of one or m o re m a nufacturi ng, production, or operating facilities em ploy ing

m o re than 250 persons or having gross annual sales or expenditures exceeding $25

m illion if authority to sign docum ents has b een assigned or delegated to the m a nager in

accordance with operating procedures; or

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

4. By a duly authorized representative (a dul y authorized representative m a y be either a

nam e d individual or any individual occupy ing a nam e d position) only if:

a. The authorization is m a de 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 m a nager, operator of a well or well field, superintendent,

or position of equivalent responsibility , or

c. For m unicipality

, 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 ex am ined and am fam iliar with the inform ation

subm itted in the attached docum ent; and based on m y inquiry of those individuals im m e diately

responsible for obtaining the inform ation, I belie ve the subm itted inform ation is true, accurate,

and com p lete. I am aware there are significant penalties for subm itting false inform ation,

including the possibility of fine or im prisonm ent.

Nam e & Title (print or ty pe) License No.

S i g n a t u r e D a t e

Nam e & Title (print or ty 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 showing the location of the Class V injection

well or facility and a one-m ile radius area surrounding the well or facility.

2. USGS geologic quadrangle or regional geologic m a p showing the subsurface

structure in the area of the well or facility, from the surface to the injection zone.

3. Schem a tic diagram of the injection well showing construction details and

m a terials of the injection well.

4. Chem ical analysis data of injection fluid, if required.

5. Process description of the treatm e nt or other process which is the source of the

injection fluid, if required.

6. Procedure f o r operation and m a intenance of the injection well or f acility, if

required.

7. Geologic/hydrogeologic inform ation coll ected during the planning, construction

and design phases of the f acility and injection well.

8. Blueprints f r om the f acility showing the injection well and portions of the f acility

which will or m a y contribute injectate to the injection well, including storm

runoff waters.

9. Construction diagram s depicting erosion and sedim e nt controls.

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