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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 5 4 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 9 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _____C_a_r_o_l_C__h_e_n____________________ (lead), ______C__a_r_la__F_o_y_____________________ Start Time: __4_:_2_8__p_m__ 4:29 pm ____________________________________ , _______________________________________ 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__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 & #: ______S__T_._R_E__G_I_S__S_W__D__S__#_9__-4_________________A_P_I_N__o_._0__9_-_1_1__3_-_2_0__1_7_5_______P_A__N_o__._3_1__1_6__3_5__ Well Type (see table): __P_r_o_d__u_c_e_d__W__a_t_e_r__D_i_s_p_o__s_a_l_(_P_W__D__)____________ State Permit: ________O__G____9_4__1__________ Latitude (N): ________3_0_._9_5_7_6_1__7_________ Longitude (W): _______-_8_7_._1_7_2_9_3_7________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing PBTD: 6821' Other: ___s_u_r_fa_c_e__c_a_s_in_g__9_5__/_8_"_a_t_2_1_9__2_' _____________________________________ Total Depth (ft): __6__9_0__0_'__ Inner Casing Size (in):7_"_a_t_6_9_0_0_' Tubing Size (in)4:_1__/2__" _at_6__1_08'Packer Depth (ft): _6__1_0__0_'_ Inj. Zone: Open Hole; Perforated; Top(ft) _6__3_3__4_'_ Bottom(ft): ___6__7_1_8__' __ Max. Injection Pressure (psig): 1_8__0_0__p_s_i Field Measurements and Observations Latitude (N): ______N_o__G__P_S__0_0__0_________ No GPS 000 Longitude (W): ________________________ Elevation (ft): ____________ EPA GPS ID: _S_C__8_2__8_4_ Well Status (see table): ____T_A____ If not Active, Reported Date Last Active: ___4_/_0__5_/_2_0__1_2_____ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _A__lt_h_o__u_g_h__t_h_i_s_w__e_l_l _is__i_n_a_c_t_i_v_e_,_t_h_e__t_u_b_i_n_g__g_a__u_g_e______________________________________________________ __re__a_d_s__4_5__0__p_s_i_,_i_s_p__a_r_ti_a_l_ly__f_il_le__d_w__i_th__f_l_u_id__. _________________T_u_b__in_g__g_a_u_g__e_: ___________4_5_0___p_s_i__________ ____________________________________________________________P_r_o_d_u__c_ti_o_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_l_o_w__li_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:_38_:4_3_-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 5 4 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 9 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______S_t_._R__e_g_i_s_S__W__D_S__#__9_-_4_________S_t_a_t_e__P_e__rm__i_t_N__o_._O__G____9_4_1__________A__P_I_N__o_._0__9_-_1_1_3__-2__0_1__7_5__________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_____C_a__ro__l _C_h__e_n_______________________EPA Camera ID: _______S_C_8__2_8_4_________________________ Photo ID: __D__S_C_N__1_3__4_8_____Time: __4__:2__8__p_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_a_n__d__id_e__n_t_if_i_c_a_t_io_n__s_i_g_n______________________________________________________ Photo ID: __D__S_C_N__1_3__4_9_____Time: __4_:_2_8__p__m___ Lat (N): _____N_o__G__P_S__0__0_0_____ Long (W) _______N_o__G__P_S__0_0__0____ Description: ___p_r_o_d_u__c_t_io_n__g_a__u_g_e__r_e_a_d__s_0__p__s_i___________________________________________________________ Photo ID: __D__S_C__N_1__3_5_0_____Time: __4__:2__8__p_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__r_e_a_d__s_0__p__s_i ______________________________________________________________ Photo ID: ___D_S_C__N_1__3_5__1____Time: __4_:_2_9__p__m___ Lat (N): _____N__o_G__P_S__0__0_0_____ Long (W) _______N__o_G__P_S__0__0_0____ Description: t_u_b__in__g_g__a_u_g_e__r_e_a_d__s_4__5_0__p__s_i,_b__u_t_g__a_u_g_e__i_s__p_a_r_t_ia_l_l_y_f_il_l_e_d__w_i_t_h__fl_u_i_d__- _is__i_t_a_c_c_u__r_a_t_e_?__________ 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_:3_9:_09_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18