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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 EPA Well ID#: F L S 1 1 3 0 0 7 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 4 5 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C_a_r_o_l_C__h_e_n___________________ (lead), ______C_a_r_l_a_F_o__y_____________________ Start Time: _9_:_4_0__a__m__ 9:45 am ____________________________________ , _______________________________________ End Time: __________ Facility Contact Information Facility Name:__M__a_v_e_r_i_c_k__N_a_t_u_r_a__l _R_e_s__o_u_r_c_e_s_,__L_L_C_____________(_B_r_e_i_t_b_u_r_n__O_p__e_r_a_t_in__g_,_L_P__)__________________ Street Address:_5__4_1__5__O_i_l _P_l_a_n_t__R_d_______________________________________________________________________ City: _____J_a_y________________________ County: ___S__a_n_t_a__R_o__s_a_________________ State:___F_L____ Zip: _3__2_5__6_5__ Nature of Business: _____o_i_l _a_n_d__g_a__s_p__ro__d_u_c_t_i_o_n___________________________________________________________ Facility Owner/Operator: _M__a_v_e__r_ic_k__N__a_t_u_r_a_l_R__e_s_o_u__rc_e__s_,_L_L_C________________ Phone: _8__5_0__-6__7_5_-_1_7__0_2_________ Email: ________________________________________________________________________________________________ Facility Contact (if different): __A_l__J_o_n_e_s_,__P_l_a_n_t__S_u_p_e__r_in_t_e_n__d_e_n__t _______________ Phone: __2_5_1__-2__2_7__-3__3_1_9_________ O/O Mailing Address: ___5_4__1_5__O__il_P__la__n_t_R__d________________________________________________________________ City: ______J_a_y_______________________ County: ____S__a_n_t_a__R_o__s_a________________ State:__F_L_____ Zip: __3_2__5_6_5__ Well Data from File Well Name & #: __C_.__D_._H__e_l_m__s_E__t_a_l_#_5__-4__________________A_P__I _N_o__._0_9__-1__1_3__-2__0_0_6__3_______P__A__N_o_.__3_0_9__8_9__0____ Well Type (see table): __E_n_h__a_n_c_e__d_O__i_l _R_e_c__o_v_e_r_y__(E__O_R__) _______________ State Permit: ______O_G____5__5_8_____________ Latitude (N): ______3__0_._9_6__8_9__2_2_________ Longitude (W): ______-8__7_._1_4__3_9_4__7_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 16019' Other: ____s_u_r_fa_c_e__c_a_s_in_g__9_5__/8__" _a_t_3_8_6__1_' ______S_m_a__ck_o__ve_r__F_o_rm__a_t_io_n_____________ Total Depth (ft): ___1_6_1__1_0__' Inner Casing Size (in):7_"_a_t_1_6_1__06T' ubing Size (in):3__1_/_2_"_a_t_1_5_57P0a'cker Depth (ft): 6_1__0_0__p_s_i Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5_7__0_8__' Bottom(ft): __1_5__8_2__1_'__ 7500 N2 gas 4400psi PW Max. Injection Pressure (psig): ________ Latitude (N): ____N__o_G__P_S__0__0_0___________ Longitude (W): ____N__o__G_P__S__0_0_0_________ Elevation (ft): ____________ EPA GPS ID: S__C_8__2_8_4__ Well Status (see table): ___T_A_____ If not Active, Reported Date Last Active: 3__/_2_0_/_2_2__F_a__il_e_d____ Nature of Injected Fluid(s) if any: ___________________________________________M__e_c_h_a_n_i_c_a_l_I_n_te__g_ri_t_y_T_e_s_t__(M__I_T_) ___ Field Measurements and Observations General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ Tubing Gauge: 0 psi _____________________________________________________________________________________________________ __________________________________________________________P_r_o_d_u_c_t_io__n_G__a_u_g_e_:______0__p_s_i_________________ __________________________________________________________S_u_r_f_a_c_e__G_a_u_g_e__: ________0__p_s_i_________________ __________________________________________________________F_lo__w__L_in_e__G_a__u_g_e_:_______0__p_s_i_________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Name:_______C_a_r_o_l_C_h__e_n_______________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_53_:4_1_-0_4_'0_0'___ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18 Inspection ID Field Measurements and Observations (Cont.) Class I and II Well Inspection 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#: F L S 1 1 3 0 0 7 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 4 5 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ C. D. Helms Etal #5-4 OG_558 _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: ____C__a_r_la__F__o_y__________________ EPA Camera ID:_____________S__C_8_2__8_4_________________________ Photo ID: _D__S_C__N_1__3_7_1______Time: __9_:_4_2__a_m____ Lat (N): ____N__o__G_P__S__0_0__0_____ Long (W) _____N__o__G_P_S__0__0_0______ Description: __w__e_l_l_i_d_e_n_t_i_fi_c_a_t_i_o_n__s_i_g_n__a_t_t_h_e__e_n__tr_a__n_c_e___________________________________________________ Photo ID: _D__S_C_N__1_3__7_2______Time: __9_:_4_4__a_m____ Lat (N): ____N__o__G_P__S__0_0__0_____ Long (W) ____N__o__G_P__S__0_0_0_______ Description: ___in_j_e_c_t_i_o_n__w_e__ll____________________________________________________________________________ Photo ID: _D__S_C_N__1_3__7_3______Time: __9_:_4_5__a_m____ Lat (N): _____N_o__G__P_S__0_0__0_____ Long (W) ____N__o_G__P_S__0__0_0_______ Description: ___f_lo__w__li_n_e__p_r_e_s_s__u_r_e__g_a_u_g_e__r_e_a__d_s__0__p_s_i____________________________________________________ Photo ID: _D__S_C__N_1__3_7_4______Time: __9_:_4_5__a_m____ Lat (N): _____N_o__G__P_S__0_0__0_____ Long (W) ____N_o__G__P_S__0_0__0_______ Description: ___i_n_j_e_c_t_io__n_t_u__b_in__g_g__a_u_g_e__r_e_a__d_s__0__p_s_i______________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ UIC Inspector UIC Inspector Carol Chen Name:_______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.0_6_.20_2_1_:5_4:_11_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18