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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 Phone: (404)562-9424 EPA Well ID#: F L S 1 1 3 0 0 Year-Month-Day: 2 0 2 4 - 0 5 - EPA Permit # (or RA): Page 1 Of 2 1 0 1 2 Inspector(s): _______C_a_r_o_l_C_h__e_n__________________ (lead), _______C_a__rl_a__F_o_y____________________ Start Time: 1__0_:_5_8__a__m_ ____________________________________ , ______________________________________ End Time: _1_1__:0__0__a_m_ 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__re__it_b_u__rn__O__p_e_r_a_t_i_n_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 & #: __B_E_S__S_I_E__J_O_Y_N__E_R__,_E_T_A__L_#__1_8__-3_________A_P__I_N__o_._0_9__1_1__3_2_0__1_7__9______P_A__N__o_._3__1_1_6__3_8_________ 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____9_6__7___________ Latitude (N): ________3__0_.9_4__0_7_2_2_________ Longitude (W): _____-_8_7_._1_5_0_9__4_4_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15770' Other: ___su__rf_a_c_e_c_a_s_i_n_g_9__5_/_8_"_t_o__3_8_6_5_'______________________________________ Total Depth (ft): _1__5_8__3_9_'__ 7" at 15822' 2 7/8" 15162' Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): _1_5__1_0_0__' 7500 N2 gas Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5_5_4_5__' _ Bottom(ft): __1_5__7_7_0_'___ Max. Injection Pressure (psig):44__0_0_p_s_i_P_W Field Measurements and Observations Latitude (N): ___N__o__G_P__S__0_0__0___________ Longitude (W): ____N__o_G__P_S__0__0_0_________ Elevation (ft): ____________ SC8284 AC EPA GPS ID: _________ Well Status (see table): _________ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _____N_i_t_ro__g_e_n__(_N__)__g_a_s_____________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _T_h_i_s__w_e_l_l_i_s_a__c_t_iv_e__ly__in__je_c_t_i_n_g__n_i_tr_o__g_e_n__g_a_s_.___________________________________________________________ Tubing Gauge: 5000 psi _____________________________________________________________________________________________________ ________________________________________________________P_r_o_d__u_c_ti_o_n__G_a_u__g_e_:_______0__p_s_i_________________ ________________________________________________________S_u__rf_a_c_e__G_a__u_g_e_:___________0__p_s_i________________ ________________________________________________________F_l_o_w__L_i_n_e__G_a_u_g_e__: _____________________________ _____________________________________________________________________________________________________ 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:_46_:1_6_-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 2 1 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______B_E__S_S_I_E__J_O_Y_N__E_R__,_E_T__A_L__#_1_8__-3_______________O_G____9__6_7_______________________A_P_I__N_o_._0__9_1__1_3__2_0_1__7_9__ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _________C_a_r_l_a__F_o_y______________ EPA Camera ID:_____________S_C_8__2_8_4__________________________ Photo ID: __D__S_C__N_1__4_0_1_____Time: _1__0_:_5_8__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__w_e_l_l_, _id__e_n_t_if_i_c_a_t_io__n__s_ig_n__,_D__A_N_G__E_R__s_i_g_n__: _H___S__M__a_y__b_e__P_r_e_s_e__n_t_.._.K__e_e_p__O__u_t_._..________ Photo ID: __D__S_C__N_1__4_0_2_____Time: _1__0_:_5_9__a_m___ Lat (N): ___N_o__G__P_S__0_0__0_______ Long (W) No GPS 000 ______________________ Description: __p_r_o_d_u__c_ti_o_n__g_a__u_g_e__r_e_a_d__s_0__p__s_i ____________________________________________________________ Photo ID: __D__S_C__N_1__4_0__3____Time: _1_0__:5__9__a_m___ Lat (N): __N__o__G_P__S__0_0_0________ Long (W) ___N__o__G_P__S__0_0__0_______ Description: __s_u_r_f_a_c_e__g_a_u__g_e__a_n_d__p_r_o_d__u_c_t_io__n__g_a_u_g__e_s__re__a_d__0__p_s_i_________________________________________ Photo ID: __D__S_C__N_1__4_0_4_____Time: _1__1_:_0_0__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_je__c_t_io_n__t_u_b__in_g__g_a__u_g_e__r_e_a_d__s_5__0_0__0__p_s_i___________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ 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_: 2_0_24_.0_6_.20_2_1_:4_6:_43_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18