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SECTION I.DATE PREPARED:Enter da e in order of year,month, SECTION 4.FACIL NAME&LOCATION(CONT'D.): and day. I. Numeric County Code. Insert the numeric county code from the Federal Information Processing Standards Publication(FIPS SECTION 2.FACILITY ID NUMBER: In the first two spaces,insert Pub 6-1)June 15, 1970,U.S.Department of Commerce, the appropriate U.S.Postal Service State Code.In the third space,insert National Bureau of Standards.For Alaska,use the Census Division one of the following one letter alphabetic identifiers: Code developed by the U.S.Census Bureau. D-DUNS Number, J. Indian Land. Mark an"x"in the appropriate box(Yes or No) G-GSA Number,or to indicate if the facility is located on Indian land. S-State Facility Number. In the remaining spaces,insert the appropriate nine digit DUNS,GSA,or SECTION 5.LEGAL CONTACT: State Facility Number.For example,A Federal facility(GSA- A. Type. Mark an"x"in the appropriate box to indicate the type 123456789)located in Virginia would be entered as:VAG]23456789. of legal contact(Owner or Operator).For wells operated by lease, the operator is the legal contact. SECTION 3.TRANSACTION TYPE: Place an"x"in the applicable B. Name. Self Explanatory. box.See below for further instructions. C. Phone. Self Explanatory. Deletion. Fill in the Facility ID Number. D. Organization. If the legal contact is an individual,give the First Time Entry. Fill in all the appropriate information. name of the business organization to expedite mail distribution. Entry Change. Fill in the Facility ID Number and the information E. Street/P.O.Box. Self Explanatory. that has changed. F. City/Town. Self Explanatory. Replacement. G. State. Insert the U.S.Postal Service State abbreviation. H. Zip Code. Insert the five digit zip code plus any extension. SECTION 4.FACILITY NAME AND LOCATION: 1. Ownership. Place an"x"in the appropriate box to indicate A. Name. Fill in the facility's official or legal name. ownership status. B. Street Address. Self Explanatory. C. Latitude. Enter the facility's latitude(all latitudes assume SECTION 6.WELL INFORMATION: North Except for American Samoa). A. Class and Type. Fill in the Class and Type of injection wells D. Longitude. Enter the facility's longitude(all longitudes assume located at the listed facility.Use the most pertinent code West except Guam). (specified below)to accurately describe each type of injection E. Township/Range. Fill in the complete township and range. well.For example,2R for a Class II Enhanced Recovery Well,or The first 3 spaces are numerical and the fourth is a letter 3M for a Class III Solution Mining Well,etc. (N,S,E,W) specifying a compass direction.A township is North B. Number of Commercial and Non-Commercial Wells. or South of the baseline,and a range is East or West of the Enter the total number of commercial and non-commercial wells principal meridian(e.g.,132N,343W). for each Class/Type,as applicable. F. City/Town. Self Explanatory. C. Total Number of Wells. Enter the total number of injection G. State. Insert the U.S.Postal Service State abbreviation. wells for each specified Class/Type. H. Zip Code. Insert the five digit zip code plus any extension. D. Well Operation Status. Enter the number of wells for each Class/Type under each operation status(see key on other side). CLASS I Industrial,Municipal,and Radioactive Waste Disposal Wells CLASS III(CONT'D.) used to inject waste below the lowermost Underground Source of Drinking Water(USDW). TYPE 3S Sulfur Mining Well by Frasch Process. 3T Geothermal Well. TYPE 11 Non-Hazardous Industrial Disposal Well. 3U Uranium Mining Well. iM Non-Hazardous Municipal Disposal Well. 3X Other Class III Wells. IH Hazardous Waste Disposal Well injecting below the lowermost USDW. CLASS IV Wells that inject hazardous waste into/above USDWs. IR Radioactive Waste Disposal Well. ix Other Class 1 Wells. TYPE 4H Hazardous Facility Injection Well. 411 Remediation Well at RCRA or CERCLA site. CLASS II Oil and Gas Production and Storage Related Injection Wells. CLASS V Any Underground Injection Well not included in Classes I TYPE 2A Annular Disposal Well. through IV. 2D Produced Fluid Disposal Well. 2H Hydrocarbon Storage Well. TYPE 5A Industrial Well. 211 Enhanced Recovery Well. 5B Beneficial Use Well. 2X Other Class II Wells. 5C Fluid Return Well. 5D Sewage Treatment Effluent Well. CLASS III Special Process Injection Wells. 5E Cesspools(non-domestic). 5F Septic Systems. TYPE 3G In Situ Gassification Well 5G Experimental Technology Well. 3M Solution Mining Well. 5H Drainage Well. 5I Mine Backfill Well. 51 Waste Discharge Well. EPA Form 7520-16(Revised 8-01)