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Underground Injection Control - Forms and Sample Documents
Topic Related Links
Regional Water Links
National Water Links
- Federal & State Program Performance Summary (7520s)
- Owner/Operator Forms
- Owner/Operator Forms Available in Excel
- Sample Financial Forms
- For Class V Well Owner/Operator
- Apply for a Permit: Example Permit Application & Other Permit Documents
- Sample Monitoring Reports & Other Forms
- Staff members are also available to answer questions
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 from Adobe Reader (Some forms are available in WordPerfect, MS Word, and Excel for added convenience). Forms can be completed by hand; by typewriter; or on your PC after downloading.
You will need the free Adobe Reader to view some of the files on this page. See EPA's PDF page to learn more.
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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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
Some Class V wells will require a permit. In these cases, the owner/operator must submit a permit application.
| 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. We have 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 |
|
Note: Owners/Operators must submit Pre-Closure Notification forms before closing a Motor Vehicle Waste Disposal Well. See Closure Guidelines for Facilities with Motor Vehicle Waste Disposal Wells (PDF) (2pp, 11Kb) for more information. |
||
| 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 (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) | ||
Apply For a Permit & Other Example Permit 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, 16 K) | quarter_new.wpd | quarter_new.doc |
| Sample Annual Monitoring Form (PDF) (1 p, 9 K) | annual.wp5 | annual.doc |
| Form to Report Unwitnessed Mechanical Integrity Test (PDF) (1 p, 38 K) | unwitmit_new_form.wp5 | unwitmit_new_form.doc |
| Instructions for Unwitnessed Mechanical Integrity Tests (PDF) (2 pp, 24 K) | unwitmit_new_instructions.wp5 | unwitmit_new_instructions.doc |