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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program EPA Well ID#: F L S 1 1 3 0 0 2 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 EPA Permit # (or RA): Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C__a_r_o_l_C_h_e_n___________________ (lead), _______C_a__rl_a_F__o_y____________________ Start Time: _1_2_:_0_6__a__m_ ____________________________________ , _______________________________________ End Time:1__2_:_1_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________________________________________________________ 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_._B__R_A__G_G__#__2_2__-1_______________________A_P_I__N_o_.__0_9__1_1_3__2_0__0_6_4_____P_A__N__o_._3__1_1_5__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_9___________ Latitude (N): ______3_0_._9_3__7_2__2_7__________ Longitude (W): ____-8__7_._1_5__9_3__4_7_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15907' Other: ___s_u_r_f_a_c_e__c_a_s_in__g_1__0_3__/_4_"_t_o__3_8_2_1__' _________________________________ Total Depth (ft): __1_5_9__9_9__' _ 7" at 15998' 2 7/8" at 15590' Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): _1_5__2_3__9_' Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5_6_7_8_'__ Bottom(ft): __1_5_8_0__0_' ___ 7500 N2 gas Max. Injection Pressure (psig):4_4_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__it_r_o_g_e_n__(_N___)_g_a__s_i_n_j_e_c_t_io__n__________________________________________ 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_ti_v_e_l_y_i_n_j_e_c_t_in__g_n__it_r_o_g_e_n__g_a__s_.___________________________________________________________ ________________________________________________________T_u_b__in_g__G_a_u__g_e_:____________5_5__0_0__p__s_i ___________ ________________________________________________________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__ro_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:_47_:1_7_-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 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ __________C__. _D_.__B_r_a_g_g__#__2_2_-_1__________________O__G___5__5_9_________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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_4_2__3_____Time: _1_2_:_0_7__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_ll__id_e__n_t_if_i_c_a_t_io__n_s__ig_n__a__t _p_r_o_p_e__r_ty__e_n_t_r_a_n__c_e______________________________________________ Photo ID: __D_S__C_N__1_4_2__4_____Time: _1_2_:_0_9__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____________________________________________________________________________ Photo ID: __D_S__C_N__1_4__2_5_____Time: _1_2_:_0_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__ti_o_n__g_a_u__g_e__b_o_t_h__r_e_a_d__0__p__s_i ____________________________________ Photo ID: __D__S_C_N__1_4__2_6_____Time: 1__2_:1__0_a_m_____ Lat (N): ___N__o__G_P__S__0_0_0_______ Long (W) ____N_o__G__P_S__0_0__0_______ Description: __in__je_c__ti_o_n__t_u_b_i_n_g__g_a__u_g_e__r_e_a_d_s__5__5_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_7:_44_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18