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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 7 8 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 5 0 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C_a_r_o_l_C_h_e__n___________________ (lead), ______C_a_r_l_a_F__o_y_____________________ Start Time: _9__:3__4__a_m___ ____________________________________ , _______________________________________ End Time: _9_:_3_8__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 & #: _______J_o_h__n__W__C__a_n_n_o__n__#_4_0__-1__0___________________________________A_P__I:_0__9_-1__1_3_-_2_0_1__9_6______ Well Type (see table): ______________N__I______________________________ State Permit: ___O__G___1__0_5_4_______________ Latitude (N): _____3_0__.9__5_9_7__5_6__3_4________ Longitude (W): ____-_8_7__.1__4_1__2_1_3__1_4______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing Other: _M__A_X_I_N_J_E_C_T_I_O_N_=_6__,6_0_0__P_W__/_9_,6__0_0_N______S_F_C__C_S_G_:_9___"__3_9_8_9_'_____________ Total Depth (ft): _1__5_8_3__4_' __ Inner Casing Size (in): 7_"__1_5_7_9__4' Tubing Size (in):3____"_1__5_4_6_5' Packer Depth (ft): ________ Inj. Zone: Open Hole; X Perforated; Top(ft) ________ Bottom(ft): ___________ 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): ____N__I___ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): __H___S__D_E_T__E_C_T_I_O__N__S_Y_S__T_E_M___IN___P_L_A_C__E__________________ __T_h_i_s_w__e_l_l _w_a__s_n__o_t_c_o__n_v_e_r_t_e_d__t_o__in_j_e_c_t_i_o_n__a_n_d__r_e_m__a__in_s__a_s__a_n__i_n_a__c_ti_v_e__p_r_o_d_u__c_e_r_.______________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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:_54_:4_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 EPA Well ID#: F L S 1 1 3 0 0 7 8 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 5 0 Phone: (404)562-9424 Page 2 Of 2 (Cont) ____J_o_h_n__W___C_a__n_n_o_n__#__4_0__-1__0_______O_G____1_0__5_4______________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _____C__a_r_la__F_o__y_________________ EPA Camera ID:_______S__C_8_2__8_4_______________________________ Photo ID: __D_S__C_N__1_3__6_6_____Time: __9_:_3_4__a__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_ti_o_n__w__e_l_l _w_i_t_h__a_n__id__e_n_t_if_i_c_a_t_io__n__s_ig_n_______________________________________________ Photo ID: __D__S_C_N__1_3__6_7_____Time: __9_:_3_4__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__c_a__s_in__g_p__re__s_s_u_r_e__r_e_a_d__s_0__p__s_i ___________________________________________________ Photo ID: __D__S_C_N__1_3__6_8_____Time: __9_:_3_5__a__m___ Lat (N): ___N__o__G_P_S__0__0_0_______ Long (W) ____N_o__G__P_S__0_0__0_______ Description: ____p__ro__d_u_c_t_i_o_n__c_a_s_i_n_g__p_r_e_s_s_u__r_e_r_e_a__d_s__0__p_s_i________________________________________________ Photo ID: __D__S_C__N_1__3_6_9_____Time: __9_:_3_5__a__m___ Lat (N): ___N__o_G__P_S__0__0_0_______ Long (W) ___N__o__G_P__S__0_0__0_______ flow line pressure reads 0 psi Description: ___________________________________________________________________________________________ Photo ID: __D__S_C__N_1__3_7_0_____Time: __9_:_3_6__a_m____ Lat (N): ___N__o_G__P_S__0__0_0_______ Long (W) ___N__o__G_P__S__0_0__0_______ Description: _____fa__rt_h_e__r_b_a__c_k_,_f_lo__w__li_n_e__p_r_e_s__s_u_r_e__re__a_d_s__0__p_s_i____________________________________________ 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_: _20_24_.0_6_.2_0 _21_:5_5_:13_-_04_'0_0_' ___ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18