Document 41DjyKNEVXREqMqkQeB4M51Q

DownloadSearchable PDFRandom document
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 4 7 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 3 1 Page 1 Of 2 Inspector(s): __________________________________ (lead), ___________________________________ Start Time: _4_:_4_5__p__m__ ____________________________________ , _______________________________________ End Time: _4_:_4_9__p__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_r_e_i_tb__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 & #: ______L_a__w_r_e_n__c_e__L_._M__a_l_o_n_e__E_t__U_x__#_4__1_-_4_A____________________A_P__I _N_o__. _0_9__-1__1_3_-_2_0__1_6__7_-_0_1____ Producer (EOR if converted to injection) Well Type (see table): ______________________________________________ State Permit: _O_G____9_4__4_A____P__A_#_3__0_9__9_0_1__ Latitude (N): ____3__0_._9_5__6_7_5__6_5__4________ Longitude (W): ____-8__7_._1_5_6__1_0__7_6_2_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing Other: _in__te__r_m_e__d_i_a_r_y_c_a__s_in_g__7____"_@__1_5__7_4__6_'___s_u_r_f_a_c_e__c_a_s_i_n_g__1_6__"_@__3_7__8_0_'__ Total Depth (ft): _1_5__7_1__2_'__ Inner Casing Size (in):5___"_1__4_9_94T' ubing Size (in):_3___"_1_4_9__7_6' Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) _1_5_6__8_9_'_ Bottom(ft): __1_5_7__4_1_'___ Max. Injection Pressure (psig): ________ 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): ____________ EPA GPS ID: _S_C__8_2__8_4_ Well Status (see table): ___A__C____ 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__In__je_c__ti_o_n___________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _T_h__is__w_e__ll_i_s__a_c_t_iv_e__ly__in__je__c_ti_n_g__N__it_r_o_g_e_n__(_N___) _G_a__s_._____________________________________________________ _________________________________________________________T_u__b_in_g__g_a_u__g_e_: ____________2__0_0__p_s_i____________ _________________________________________________________P__ro_d__u_c_t_io_n__g_a_u_g_e__: ________0__p__s_i ______________ Surface gauge: 0 psi _____________________________________________________________________________________________________ _________________________________________________________F__lo_w__l_in__e_g_a_u__g_e_:_____________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Carol Chen Name:_______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_35_:5_9_-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 EPA Well ID#: F L S 1 1 3 0 0 4 7 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 3 1 Phone: (404)562-9424 Page 2 Of 2 (Cont) ___L_a_w__r_e_n_c_e__L_.__M__a_lo__n_e__E_t_U__x__#_4_1__-4__A______O_G____9_4__4_A_____A_P__I _N_o__._0_9__-1__1_3__-2__0_1_6__7_-_0_1___P__A_#_3__0_9__9_0__1_ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen SC8284 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: __D_S__C_N__1_3_5__6_____Time: __4_:_4_7__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__7_____Time: __4_:_4_7__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__rf_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_8_____Time: __4_:_4_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__2_0_0__p__s_i___________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ 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_: 2_0_24_.0_6_.20_2_1_:3_6:_26_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18