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Inspection ID Mechanical Integrity Test Form US Environmental Protection Agency - Region 4 Underground Injection Control Program 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 EPA Well ID#: K Y S 0 0 9 N O N E Year-Month-Day: 2 0 2 3 - 0 9 - 1 9 EPA Permit # (or RA): N O N E Phone: (404)562-9424 KY 111143 Page 1 Of 2 Inspector(s): _C_a__rl_W___e_ll_e_r______________________ (lead),__________________________________ Start Time: _1_0__:3__7____ ____________________________________, ____________________________________ End Time: _1_1__:4__7____ Facility Contact Information Facility Name:_L_o_g__s_d_o_n__V__a_l_le__y__O_i_l______________________________________________________________________ Street Address:__1_0_5__B__e_d_f_o_r_d__C__o_u__rt_____________________________________________________________________ City: _H__o_r_s_e__C__a_v_e___________________ County: H__e_a__r_t _________________________ State:_K__Y_.____ Zip: _4_2__7_4_9___ Nature of Business: _O__il__P_r_o_d__u_c_t_io__n______________________________________________________________________ Facility Owner/Operator: _C__h_a_r_l_e_s_S__t_in_s_o__n_________________________________ Phone: _2_7_0__-7__8_6_-_2_6_6_3___________ Email: _e_s_t_i_n_s_o_n_@___s_c_rt_c_._c_o_m_____________________________________________________________________________ Facility Contact (if different): _B__il_li_e__M__a_t_h_e_w__e__s_______________________________ Phone: _2_7__0_-_6_7_0__-7__2_6_4__________ O/O Mailing Address: ____________________________________________________________________________________ City: _______________________________ County: _______________________________ State:________ Zip: _________ Well Data from File Well Name & #: _B_i_ll_y_J__o_e__C_a_u__d_e_l_U__IC__#_1__________________________________________________________________ Well Type (see table): _2_-_R___________________________________________ State Permit: __________________________ Latitude (N): _3_7_._1_5_9__7_7_________________ Longitude (W): _-_8_5_._7_9_6_2__8______________ Elevation (ft): _6_9__3_' _______ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing Other: __________________________________________________________________ Total Depth (ft): _P_B__-_7_0_0__' _ Inner Casing Size (in): _4_._5_"____ Tubing Size (in):_2__3_/_8_"____ Packer Depth (ft): _6_5__0_' ___ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _3_7__.1__5_9_8_1_________________ Longitude (W): _-_8_5_._7_9__6_2_9______________ Elevation (ft): _6_7__5_' _______ EPA GPS ID: _s_x_8__1_2_3__ Well Status (see table): _T_A_______ If not Active, Reported Date Last Active: _N__/A_______________ Nature of Injected Fluid(s) if any: _P_r_o__d_u_c_e__d________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Tubing PSI: _0_____________ Pump PSI: _n_o__p__u_m__p______ Annulus PSI: _t_e_s_t_p__s_i_____ Annulus Fluid:_H__2_/_o___N__2_____ Gauge: Digital/Analog; _EPA/Operator; Last Calibrated: _n_e_w_______ Gauge Notes: _n_e_w___in__b_o_x____________ _____________________________________________________________________________________________________ Test Attempt #:_1___ Casing/Tubing/Annulus Start Time: _1_0__:5_5___ End Time: _1_1__:2__5___ Duration (min):_3_0______ Initial Pressure (psi): _3_0__9_______ Final Pressure (psi): _3_0__9________ Change (psi): _0_________ Change (%): _0____________ Test Attempt #:____ Casing/Tubing/Annulus Start Time: ________ End Time: _________ Duration (min):________ Initial Pressure (psi): ___________ Final Pressure (psi): ____________ Change (psi): __________ Change (%): _____________ See reverse for additional observations, comments and photo log Owner/Operator Representative (Optional) UIC Inspector Name:_______________________________________________ Name: _C__a_r_l _W__e__ll_e_r__________________________________ CARL WELLER (Affiliate) Date: 2023.09.27 15:37:08 -04'00' Digitally signed by CARL WELLER (Affiliate) Signature: ___________________________________________ Signature: ___________________________________________ Version 2018-04-18 Inspection ID Field Measurements and Observations (Cont.) Mechanical Integrity Test Form US Environmental Protection Agency - Region 4 Underground Injection Control Program 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 Phone: (404)562-9424 EPA Well ID#: K Y S 0 0 9 N O N E Year-Month-Day: 2 0 2 3 - 0 9 - 1 9 EPA Permit # (or RA): KY 111143 NONE Page 2 Of 2 Notes & Comments (Additional Tests as necessary, include discrepancies from database values): _________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_W__e_l_le_r________________________________EPA Camera ID: _S_X__8_1_2_3_______________________________ Photo ID: _D__S_C__0_0__2_6_9______Time: _1_0__:5__5__a_m___ Lat (N): _3_7__.1__5_9_7_9____________ Long (W) _-_8_5_._7_9__6_2_7____________ Description: _s_t_a_r_t_M__I_T__o_n__B__il_ly__J__o_e__C__a_u_d__e_l_U__IC__#_1______________________________________________________ Photo ID: _D__S_C__0_0__2_7_0______Time: _1_0__:2__8__a_m___ Lat (N): _3_7__.1__5_9_7_7____________ Long (W) _-_8_5_._7_9__6_2_7____________ Description: _w__id_e__v_i_e_w__o_f_w__e_l_l _a_r_e_a_._____________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Owner/Operator Representative (Optional) UIC Inspector Name:_______________________________________________ Signature: ___________________________________________ Name: _C__a_r_l _W__e__ll_e_r__________________________________ Digitally signed by CARL WELLER CARL WELLER (Affiliate) (Affiliate) Signature: _____________________D_at_e:_20_2_3.0_9._27_1_5:3_6:_20_-0_4'_00_' _______ Version 2018-04-18