General Instructions Form M

UIC MODIFICATION APPLICATION INSTRUCTIONS PAGE 1

GENERAL INSTRUCTIONS – FORM M

1. Where to file:

Send application to: Michelle Finney at: Division of Water and Waste Management 601 57th Street, SE Charleston, WV 25304

2. Fees:

In accordance with the West Virginia Code, Chapter 22, Article 11, Section 10©, a permit application fee shall accompany the permit application. A check or money order for the fee shall be made payable to the “Department of Environmental Protection”. You should refer to Title 47, Legislative Rule, Department of Environmental Protection, Division of Water Resources, Series 9, “Underground Injection Control Fee Schedule” to determine the amount of this fee. Permit modification applications that are deemed incomplete shall be returned to the applicant and a resubmission fee will be required to accompany the re-filed application.

FEE CALCULATION: The permit modification fee for Class 5 injection wells is calculated through the use of the following formula: the permit modification application fee is equal to the volume fee multiplied by the treatment factor multiplied by the well type factor (i.e., Permit Modification Application Fee=Volume Fee X Treatment Factor X Well Type Factor). Non-volume related Major Modifications—For an application seeking a major modification of a Class 5 UIC Permit where no discharge volume is involved, the permit modification application fee is twenty five percent (25%) of the initial permit application fee or a minimum of twenty-five dollars ($25).

Volume related Major Modification fees are calculated using Tables A, B and C

Non-volume related Minor Modifications—For an application seeking a minor modification of a Class 5 UIC Permit where no discharge volume is involved, the permit modification application fee is twenty-five dollars ($25).

Septic applications: Volume fee is to be determined by the total fluid capacity in gallons of the septic tank(s) or you may use copies of water bills from the previous year for the facility to calculate the average daily volume gallons per day discharge, or use the design flow listed on the permit to construct or final inspection form issued by the Health Department.

Septic tank and drain field constitutes “Primary Treatment”, additional aeration chamber and settling chamber constitutes “Secondary Treatment”, additional aeration and settling and sand filtration or re-circulating sand filters constitutes “Tertiary Treatment”, and all of the above constitutes “Greater than Tertiary Treatment”. If your system utilizes other treatment not listed above, contact this office for assistance in determining treatment factor.

Use Tables A (Volume Fees), B (Treatment Factors), and C (Well Type Codes & Factors) to calculate your application fee using the following formula: Permit Application Fee = (Volume Fee) X (Treatment Factor) X (Well Type Factor)

CALCULATE THE MODIFICATION PERMIT APPLICATION FEE FOR YOUR FACILITY IN THE SPACE BELOW:

Fee = (Volume Fee) X (Treatment Factor) X (Well Type Factor)

Fee = ______X ______X ______(Table A) (Table B) (Table C) Calculated Modification Application Fee = ______(Minimum $25.00; Maximum $1500.00) UIC MODIFICATION APPLICATION INSTRUCTIONS PAGE 2

TABLE A - VOLUME FEES Septic tank(s) capacity (in gallons) is: The Volume Fee is: <250 $ 50.00 TABLE C -- CLASS 5 WELL TYPE CODES & FACTORS 250 - 500 $ 75.00 WELL TYPE CODES FACTOR 501 - 1000 $ 150.00 DRAINAGE WELLS 1001 - 5000 $ 200.00 5F1 1 5001 - 50,000 $ 400.00 5D2 1 50,001 - 100,000 $ 600.00 5D3 2 >100,000 $ 850.00 5D4 3 TABLE B - TREATMENT FACTORS 5G30 1 LEVEL OF TREATMENT TREATMENT GEOTHERMAL REINJECTION WELLS FACTOR NO TREATMENT5A5 3 3 PRIMARY5A6 TREATMENT 2.5 3 SECONDARY5A7 TREATMENT 2 1 TERTIARY5A8 TREATMENT 1.5 3 DOMESTIC>TERTIARY WASTEWATER TREATMENT DISPOSAL WELLS 1 5W9 3 5W10 1 5W11 2 5W31 2 5W32 1 5W12 1 MINERAL AND FOSSIL FUEL RECOVERY RELATED WELLS 5X13 3 5X14 2 5X15 2 5X16 2 OIL FIELD PRODUCTION WASTE DISPOSAL WELLS 5X17 3 5X18 2 INDUSTRIAL/COMMERCIAL/UTILITY DISPOSAL WELLS 5A19 2 5W20 3 RECHARGE WELLS 5R21 1 5B22 1 UIC MODIFICATION APPLICATION INSTRUCTIONS PAGE 3

5S23 1 MISCELLANEOUS WELLS 5N24 4 5X25 3 5X26 1 5X29 3 5X27 3

Item I – Enter the facility’s official name or legal name. (Do not use colloquial name).

Item II – Give the name, title, and work telephone number of a person who is thoroughly familiar with the operation of the facility and with the facts reported in the application and who can be contacted by reviewing office if necessary.

Item III – Give the complete mailing address where correspondence should be sent.

Item IV – Give the location of the facility (i.e. Street, City, nearest town or post office, County, zip code)

Item V – Give detailed description of the proposed modification.

Item VI. – State statute provides for severe penalties for submitting false information on this application form. State regulations require this application to be signed as follows:

 For corporation: by a principal executive officer of at least the level of vice-president.  For partnership for sole proprietorship: by a general partner or the proprietor, respectively.  For a municipality, State, Federal, or other public agency: by either a principal executive officer or ranking elected official.

B. Signature of cognizant official. C. Date application signed.