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Underground Injection Control - Forms and Sample Documents
- Federal & State Program Performance Summary (7520s)
- Owner/Operator Submitted
- Owner/Operator Forms Available in Excel
- Sample Financial Forms
- For Class V Well Owner/Operator
- Example Permit Application & Other Permit Documents
- Sample Monitoring Reports & Other Forms
Note: We are unable to accept electronic submissions from injection well owners and operators at this time. Forms can be viewed on your computer, downloaded, and printed. Forms can be completed on your PC after downloading or by hand or by typewriter.
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You will need Adobe Acrobat Reader, available as a free download, to view
some of the files on this page. See EPA's
PDF page to learn more about PDF, and for a link to the free Acrobat Reader. |
Owner/Operator Forms Available in Excel
The following national UIC forms are available in Microsoft Excel (.xls) format: two are courtesy of Quicksilver Resources, Inc. of Gaylord, MI: the Application to Transfer Permit and the Plugging and Abandonment Plan, with its accompanying wellbore schematic as a separate file. The third is the Well Rework Form, courtesy of Dow Chemical. Operators are welcome to download these files and complete them on their computers.
| National UIC Well Forms (PDF) | Form No. | Download Microsoft Excel Version* |
|---|---|---|
| Application to Transfer Permit (PDF) (2 pp, 54 K) | 7520-7 | transfer_8-01.xls (1 p, 27 K) |
| Rework Report (PDF) (2 pp, 84 K) | 7520-12 | rework_8-01 .xls (1 pp, 27 K) |
| Plugging and Abandonment Plan (PDF) (2 pp, 92 K) | 7520-14 | p&aplan_8-01.xls (1 p, 30 K) wellbore.xls (1 pp, 23 K) |
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* Forms should not be printed from a browser window; they should be downloaded first. ** In addition, an example of a completed Class II permit application is availablle. *** Other sample monitoring reports are available. **** Also available in WordPerfect and Microsoft Word formats. |
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Sample UIC Financial Forms
The UIC Program has prepared sample documents to make it simpler for applicants and permittees to meet certain requirements. You may view or download an Adobe PDF version and fill it in on a typewriter or you may download either a WordPerfect Version 5 or Microsoft Word version of these files and complete them on your computer. (More recent versions of word processing software should have no problem reading these files saved using the older releases.) The financial forms are samples: comparable wording is usually acceptable. Forms will be added as they become available.
In addition, a simple discussion of the different types of financial mechanisms and their requirements is available.
| View Online (PDF) | Download WordPerfect 5 Version | Download Word97 Version |
|---|---|---|
| Amendment to Standby Trust Agreement (PDF) (1 p, 10 K) | amendsta.wp5 | amendsta.doc |
| Auditor's Verification of Chief Financial Officer's Letter (PDF) (1 p, 7 K) | auditltr.wp5 | auditltr.doc |
| Chief Financial Officer's Letter for Class I Wells (PDF) (2 pp, 13 K) | classi_cfo_ltr.wp5 | classi_cfo_ltr.doc |
| Chief Financial Officer's Letter for Class II Wells (PDF) (3 pp, 14 K) | classii_cfo_ltr.wp5 | classii_cfo_ltr.doc |
| Form VII-10 (PDF) (for Blanket Bond Coverage) (1 pp, 55 K) | vii-10.wp5 | vii-10.doc |
| Irrevocable Standby Letter of Credit (PDF) (2 pp, 9 K) | ltrcred.wp5 | ltrcred.doc |
| Letter Requesting Use of Michigan State Bond (PDF) (1 p, 39 K) | ltrstbnd.wp5 | ltrstbnd.doc |
| Standby Trust Agreement (PDF) (9 pp, 24 K) | stndtrst.wp5 | stndtrst.doc |
| Surety Performance Bond (PDF) (4 pp, 13 K) | surebond.wp5 | surebond.doc |
| Trust Agreement (PDF) (9 pp, 23 K) | trustagr.wp5 | trustagr.doc |
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Class V Forms
| View Online (PDF) | Download WordPerfect 5 Version | Download Word97 Version |
|---|---|---|
| If you have a Class V well, it is your responsibility to submit inventory information to the UIC Program Director. The Region 5 UIC Program has prepared an inventory sheet with instructions to make it simpler for well owners and operators. You may download either a WordPerfect Version 5 or Word97 version of these files or view them onscreen. (More recent versions of word processing software should have no problem reading these files saved using the older releases.) | ||
| Region 5 Class V Inventory Sheet (PDF) (1 p, 45 K) | cl5invfm.wp5 | cl5invfm.doc |
| Instructions for Region 5 Class V Inventory Sheet (PDF) (1 p, 47 K) | cl5invin_08-02.wp5 | cl5invin_08-02.doc |
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Before closing a Motor Vehicle Waste Disposal Well, owners and operators are required to submit a Pre-Closure Notification Form to the US EPA. For more information about well closures, please see Closure Guidelines for Facilities with Motor Vehicle Waste Disposal Well |
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| Pre-Closure Notification Form & Instructions (PDF) (2 pp, 59 K) | preclosureform.wpd | preclosureform.doc |
| Forma de Notificación Antes de Clausura Para Posos de Clase V y Instrucciónes (Pre-Closure Notification Form and Instructions in Spanish) |
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| Forma de Notificación Antes de Clausura Para Posos de Clase V (PDF) (1 p, 21 K) | forma_de_clausura.wpd | forma_de_clausura.doc |
| Forma de Notificación Antes de Clausura Para Posos de Clase V:Instrucciónes (PDF) (1 p, 20 K) | instrucciones.wpd | instrucciones.doc |
| (A volver a página de el nuevo reglamento de talleres) | ||
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In the event that US EPA decides that a permit is necessary, the owner or operator will be notified that they must submit a permit appllication. |
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| Permit Application Form (PDF) (6 pp, 100 K) | ||
| Region 5 Class V Permit Application Instructions | clvpermap.wp5 | clvpermap.doc |
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Example Permit Application and Other Permitting Documents
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Sample Monitoring Reports and Other Forms
| View Online (PDF) | Download WordPerfect 5 Version | Download Word97 Version |
|---|---|---|
| Sample Monthly Monitoring Form (PDF) (1 p, 39 K) | monthly.wp5 | monthly.doc |
| Sample Quarterly Monitoring Form (PDF) (1 p, 39 K) | quarter.wp5 | quarter.doc |
| Sample Annual Monitoring Form (PDF) (31 p, 9 K) | annual.wp5 | annual.doc |
| Form to Report Unwitnessed Mechanical Integrity Test (PDF) (3 pp, 69 K) | unwitmit.wp5 | unwitmit.doc |
In addition, Region 5 UIC staff members are available to answer questions.
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