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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#: K Y S 0 9 1 0 1 2 2 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 Page 1 Of 2 Inspector(s): ____C__a_r_l_E_.__W__e_l_le_r________________ (lead),_____C__a_r_o_l_C__h_e_n___________________ Start Time: 1__1_:_4_3__a_m__ ____________________________________, ____________________________________ End Time:1__1_:_4_6__a_m__ Facility Contact Information Facility Name:_____W__e__s_t_K__e_n_t_u_c_k__y_E__n_e_r_g_y__R__e_s_o_u_r_c_e__s_,_L_L_C_______________________________________________ Street Address:_____3_8__3_0__V_i_n_c_e__n_t_S__ta__ti_o_n__D__r_iv_e__________________________________________________________ City: _____O__w__e_n_s_b__o_r_o_______________ County: ______H__a_n_c_o__c_k_________________ State:___K__Y___ Zip: _4__2_3__0_3__ Nature of Business: _____O__il__a_n_d__g_a__s_e__x_tr_a__c_ti_o_n___________________________________________________________ Facility Owner/Operator: ____W__e_s_t__K_e_n__t_u_c_k_y__E_n__e_r_g_y_R__e_s_o__u_r_c_e_s_,_L__L_C_______ Phone: ____2__7_0__-9__2_6_-_1_6__8_9______ Email: ___________________G__le__n_n__R_i_d_g__e_s_:__2_7_0__-3__1_6__-7__4_8__7_______________________________________________ Facility Contact (if different): ____M_r_._V__in__c_e_n_t__B_._H__a_y_d__e_n_,_J_r_._, _M__a_n_a__g_e_r_________ Phone: _____2_7__0_-_6_8_3__-3__0_5__7_____ O/O Mailing Address: _____3_8_3__0__V_i_n_c_e_n__t_S_t_a__ti_o_n__D__ri_v_e_____________________________________________________ City: ______O_w__e_n_s_b__o_r_o_______________ County: ______H_a__n_c_o_c_k__________________ State:___K_Y____ Zip: __4_2_3__0_3__ Well Data from File Field Measurements and Observations Well Name & #: _____M__a__ry__M__a_d__d_e_n_-_R__ic_h__a_r_d_s__#_W__-_7______________________________________________________ Well Type (see table): ______E_n__h_a_n_c__e_d__O_i_l_R__e_c_o_v_e__ry__(_E_O__R_)___________ State Permit: __________________________ Latitude (N): ____3__7_._7_0__2_8_1__4___________ Longitude (W): _____-8_6__.7__1_6__2_8__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: Other: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Latitude (N): ____3__7_._7_0__2_7_1__3___________ Longitude (W): _____-8_6__.7__1_6__3_4__3________ Elevation (ft): ____________ EPA GPS ID: _S_X_8__1_2__3_ Well Status (see table): ___A__B____ If not Active, Reported Date Last Active: __U_n__k_n_o_w__n________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): __W__e_l_ls__a_r_e__l_o_c_a_t_e_d__i_n__R_e__y_n_o_l_d_s__S_t_a_t_i_o_n_,_K__Y__4_2__3_6_8____ A__c_r_e_e_k__i_s_n__e_a_r_b_y_.__S_w__a_m__p_y__w__o_o_d_s__a_r_e__i_n__th__is__a_r_e_a__. _N_o__r_o_a__d_s__o_r_t_r_a_i_ls__. _N_o__o_i_l_p__ro__d_u_c_t_i_o_n_._O__v_e_r_g_r_o_w__n_._ I_n_j_e_c_t_i_o_n__li_n_e__i_s_d__is_c_o__n_n_e__c_te__d_._N__o__g_a_u_g__e_s_._A__b_a_n_d__o_n_e_d__m__a__n_y__y_e_a_r_s_._N__o__re__c_o_r_d__o_f_a__c_t_iv_e__i_n_je__c_t_io_n__. ____ _C_o__rr_o__s_io__n_i_s__a_f_f_e_c_t_in__g_t_h__e_e__q_u_i_p_m__e__n_t_. ______________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Name:_____C_a__rl__E_._W__e_l_l_e_r____________________________ Digitally signed by CARL WELLER (Affiliate) Signature:_C_A_R__L_W__E_L_L_E__R_(_A_f_fi_li_a_te_)_D_a_te_: 2_02_3._09_.0_1 1_6_:32_:2_7_-0_4'0_0'______ Name: _______C_a_r_o__l _C_h_e__n_____________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_3._08_.3_1_1_6:_12_:4_1_-0_4_'0_0'___ 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#: K Y S 0 9 1 0 1 2 2 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 Page 2 Of 2 (Cont) ___K_Y_S__0_9__1_0_1__2_2_________M__a_r_y__M__a_d_d__e_n_-_R_i_c_h_a__rd__s_#__W__-7____________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _____C_a__rl__E_._W__e_l_l_e_r____________________EPA Camera ID: SX8123 ______________________________________ Photo ID: ____2__3_4__________Time: _1__0_:_3_5__a_m___ Lat (N): ____3__7_._7_0__7_8_1__2______ Long (W) _____-8__6_._7_1_9__4_3__9______ Description: ____________o_p_e_r_a_t_o_r_'_s__s_ig_n__o__n__th__e_p__r_o_p_e_r_t_y_________________________________________________ Photo ID: ____2__3_5__________Time: _1__0_:_3_5__p__m__ Lat (N): _____3_7__.7__0_7_8__0_9______ Long (W) _____-8__6_._7_1__9_4_4__8______ Description: ____________t_a_n_k__b_a__tt_e__ry__a_n__d_o__p_e_r_a_t_o_r_'_s_s__ig_n________________________________________________ Photo ID: _____2_5__4_________Time: _1__1_:_4_5__a_m___ Lat (N): _____3_7__.7__0_2__7_4_1______ Long (W) _____-8__6_._7_1__6_2_8__6______ Description: _____________b_lu__r_ry__p_h__o_t_o__o_f_i_n_j_e_c_t_io__n__w_e__ll_c__lo_s_e__-u__p_________________________________________ Photo ID: _____2_5__5_________Time: _1_1__:4__6__a_m___ Lat (N): _____3_7__.7__0_2_7__1_3______ Long (W) _____-8__6_._7_1__6_3_4__3______ Description: _____________c_l_e_a_r_e_r__p_h_o__to__o_f__in__je__c_t_io_n__w__e_l_l_c_l_o_s_e_-_u_p________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ UIC Inspector UIC Inspector Name:______C_a_r_l__E_._W__e_l_l_e_r___________________________ Carol Chen Name: ______________________________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fil_ia_t_e_)_D_a_te_: 2_02_3._09_.0_1_16_:3_3:_09_-0_4_'00_' _____ Digitally signed by CARL WELLER (Affiliate) Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_23_.0_8_.31_1_6_:1_3:_11_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18