Class V Inventory Form
Class V Well Codes
Instructions for completing this form:
- Provide the date the form was prepared.
- Provide the name of the county where the well is located.
- Provide the name and address of the person preparing the form.
- Provide the IEPA Site Number for the facility. If a site number has not been assigned, check the box and provide the name of the township where the well is located. Other permit numbers or incident numbers should be listed in the comment section of the inventory form.
- Provide the appropriate facility transaction:
- First time entry - use the first time the facility reports a specific type of Class V well.
- Modify entry - use any time there is a change in the information previously provided in Sections 5, 6, 7, 8, and/or 10 of this form.
- Provide the name of the facility, name of facility contact and the facility address. Please note if the well(s) are located at another address and provide the street address for the well(s) in the comment section.
- Provide the name of the facility's legal owner. Also insert the owner's company and organization, telephone number, name and address. If the well is located at a private residence enter "Private" for the organization name.
- Mark the appropriate box to indicate the ownership of the well.
- Provide a description of the injection fluid. Mark the appropriate box indicating whether the injection fluid is generated on-site or off-site. If the fluid is generated off-site, provide the name and address of the facility where the fluid is generated.
- Provide the distance, in feet, to the closest drinking water well. If the distance is 200 feet or less, provide the date of completion of the drinking water well. Indicate whether the drinking water well is public or private.
- Provide the well code(s), total number of wells in each code, well status, well location and well transaction.
- Well Code(s) - refer to the attached list of Class V well types for the appropriate code(s).
- Total Wells in this Code - indicate the total number of wells for each well code indicated at the facility.
- Well Status - insert the appropriate code as indicated below:
- UC = under construction
- AC = active
- TA = temporarily abandoned
- PA = permanently abandoned
- The date and method of plugging should be included for all permanently abandoned wells.
- Well location - Provide the Latitude and Longitude for each well.
- Well transaction - Provide the appropriate code as indicated below:
- A = add, first time the inventory information has been reported for the well
- B = correction of previously submitted information
- S = change in well status
- T = change in well type
- Provide other permit numbers or incident numbers assigned to the facility in the comment section. In addition, the street address for the well(s) should be listed in the comment section if the well(s) is not located at the facility address.
Signatories to Inventory Form
All inventory forms, and accompanying information shall be signed by the injection well owner, and operator, if there is a separate well operator.
Submit the completed form to:Illinois Environmental Protection Agency
Bureau of Land - #33
1021 North Grand Avenue East
Springfield, Illinois 62794-9276