UNEV87041 UIC Permit Acknowledgment Form U220

Sep 12, 2026

UIC Permit Acknowledgment Form U220 for Nevada’s Underground Injection Control program requiring completion, signature, and return upon issuance of a new, modified, or renewed UIC permit. The form confirms the permittee understands injection operation conditions, required monitoring and sampling at specified times, routine UIC reporting obligations, the 5-day notification requirement under Part 2, and annual fee and renewal application deadlines. Includes submission due date, facility details, permit number, certification, and signature fields, plus NDEP authorization to inject/discharge details.

LanguageEnglish

CategoryForms

FormatPDF

Pages61

Reading Time21 min

AccessFree to download

UIC Permit Acknowledgment Form U220

Submission requirements

Permittee certification and acknowledgement

NDEP use only

Authorization to inject/discharge

Notification requirement table

Nevada Division of Environmental Protection Bureau of Water Pollution Control Underground Injection Control Program 901 S. Stewart St Ste 4001 Carson City Nevada 89701 Ph: 775-687-9418 Fx: 775-687-4684 UIC Permit Acknowledgment Form U220 This form shall be completed, signed and returned upon issuance of a new, modified or renewed UIC permit. This form is used to ensure that all permittees have read and understand their responsibilities under the requirements and conditions of the permit. Please ensure that this form is returned by the due date below at the address above, Attn: Permits Branch-UIC Permit Writer. Questions should be directed to the UIC Program at (775) 687-9428 or (775) 848-8118. Date Form Due (postmarked and emailed): June 5, 2023 UIC Permit Number: UNEV87041 Date form submitted to BWPC Permits Branch: Facility Name: San Emidio / North Valley Geothermal Project By signing below, you are acknowledging you understand the following: The permit contains specific conditions that the injection well(s) must be operated in accordance with. Monitoring and sampling requirements are contained in the permit, and are required to be done at specific times. Routine UIC reports are required, and must be submitted whether injecting or not. The permit contains a 5-day NDEP Notification Requirement under Part 2. Annual fees are due for this permit July 1 of each year following the original issue date, until the permit is officially cancelled. A renewal application and fee are due 180 days prior to the expiration date on the permit. I certify under penalty of law that all the information submitted on this form is accurate to the best of my knowledge. Print Name: Title: Signature: Date: NDEP Use Only Reviewed by: Date: Entered in database STATE OF NEVADA DIVISION OF ENVIRONMENTAL PROTECTION AUTHORIZATION TO INJECT/DISCHARGE In compliance with the provisions of the Nevada Revised Statutes (NRS 445A) and the Nevada Underground Injection Control and Water Pollution Control Regulations (under NAC 445A), the following Permittee is authorized to inject and discharge from a facility described below in accordance with limitations, requirements and other conditions set forth in Parts I and II hereof. Permit Number: Facility Name: Facility Address: Permittee: Permittee Address: Legal Description: UNEV87041 San Emidio / North Valley Geothermal Project Southeast corner of San Emidio Desert ORNI 36, LLC 6140 Pluma.s S. t Reno, Nevada 89511 Sections 8, 9, 16, 21 T 29N R 23E MDB&M; Washoe County, Nevada Number of Permitted Wells: Six (6) (subclass SAS) (approved wells listed in table on page 4) Other Permitted Discharges: Water discharge to surface basins (well sites) in accordance with the O&M manual; three surface discharge locations covered by permit NS00094003. Reporting Frequency: Semi-annual Special Conditions: Injection rate limits (per well and total annual average) Modified on: May 28, 2023 by Andrew Kowler Modified on: March 7, 2023 by Andrew Kowler Modified on: May 27, 2015 by Russ Land This permit shall become effective: November 19, 2013 . This permit shall expire at midnight: November 19, 2018-Extension of coverage through the time of permit renewal is contingent upon timely submission of renewal application . Th i s permit originally issued: November 12, 1987. The UIC renewal application is due 180 days prior to permit expiration. Annual Fee Due: July 1 of each year Russ Land Bureau of Water Pollution Control _________________ Andrew L. Kowler, Ph.D. | Environmental Scientist Bureau of Water Pollution Control Date 5/28/2023 Date Modified TABLEl permittee sha11 notfy the Dv1.s0n when: Activity New construction of, or conversion of existing well to, injection well Initial injection into well Any modification of injection well Testing of injection well / MIT's Construction of pro

FAQs

What is the purpose of UIC Permit Acknowledgment Form U220 for UNEV87041?

The form must be completed, signed, and returned after issuance of a new, modified, or renewed UIC permit. It ensures permittees read and understand the responsibilities and conditions in the permit.

What key responsibilities does the permittee acknowledge by signing?

The permit contains specific operating conditions for the injection well(s), monitoring and sampling requirements, routine UIC reporting obligations, and a 5-day NDEP notification requirement under Part 2. It also covers annual fee timing and renewal application requirements.

How are modification and reporting actions expected to be handled under the permit conditions?

The included conditions specify that notifications and submissions must occur within defined time frames for different activities, and that required reports and sundry notices must be submitted to the appropriate agencies.

Sep 12, 2026

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