This application covers ONLY Class V (five) injection wells that meet the requirements of Title 122, Chapter 6.
Please answer EVERY item on this application to the best of your knowledge. An incomplete application may be returned. If you have questions while filling out this application please refer to Title 7122, Chapter 10 or call (402) 471-4290 and someone will assist you.
Note: Effective Oct. 1, 2009, any individual submitting any application or form that would derive public benefit from the state must also fill out a United States Citizenship Attestation form. This applies to individuals submitting the forms on their own behalf. If applicable, please fill out the United States Citizenship Attestation form below and submit it with the relevant applications and forms.
United States Citizenship Attestation Form