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Underground Injection Control - Forms and Sample Documents
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In addition to the information here, Region 5 UIC staff members are available to answer questions.
You will need the free Adobe Reader to view some of the files on this page. See EPA's PDF page to learn more.
National UIC Forms
These UIC forms have been prepared by US EPA headquarters and made available as PDF files. Using the Adobe Acrobat Reader, you can view these files on your computer, download them and then print them if you wish. They can be completed on your PC after downloading or by hand or by typewriter. They cannot be submitted electronically at this time. In addition, three 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* |
|---|---|---|
| Permit Application Form (PDF)** (6 pp, 100 K) | 7520-6 | |
| Application to Transfer Permit (PDF) (2 pp, 54 K) | 7520-7 | transfer_8-01.xls (1 p, 27 K) |
| Injection Well Monitoring Report (PDF)***(2 pp, 71 K) | 7520-8 | |
| Completion Form (PDF) (2 pp, 59 K) | 7520-9 | |
| Completion Report (PDF) (2 pp, 81 K) (For Class II wells) | 7520-10 | |
| Annual Monitoring Report (PDF) (2 pp, 77 K) | 7520-11 | |
| 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) |
| Inventory of Injection Wells (PDF) (3 pp, 109 K) | 7520-16 | |
| Class V Well Pre-Closure Notification Form (PDF)**** (2 pp, 58 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 (PDF) (2 pp, 59 K) | preclosureform.wpd | preclosureform.doc |
| Pre-Closure Notification Form Instructions (PDF) (2 pp, 58 K) | instructions7520-17.wpd | instructions7520-17.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, 16 K) | quarter_new.wpd | quarter_new.doc |
| Sample Annual Monitoring Form (PDF) (31 pp, 9 K) | annual.wp5 | annual.doc |
| Form to Report Unwitnessed Mechanical Integrity Test (PDF) (1 pp, 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 |
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