Document 4Jjz1ax8gb0v7OokeYJXrJeEQ

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#: K Y S 0 7 7 0 0 0 1 Year-Month-Day: 2 0 2 4 - 1 0 - 2 3 EPA Permit # (or RA): K Y I 1 0 6 1 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _C_a__ro__l _C_h__e_n______________________ (lead),______L_o_n_n__ie__D__o_rn__________________ Start Time: 2__:_3_8__p__m__ ____________________________________, ____________________________________ End Time: _3_:_1_5__p__m__ Facility Contact Information Facility Name:____S__te__rl_i_n_g__M__a_t_e_r_ia__ls_____________________________________________________________________ Street Address:___1_0_0__S__i_e_r_ra__D__r_iv__e______________________________________________________________________ City: _____V__e_r_o_n__a___________________ County: ______G__a_l_la__ti_n__________________ State:__K__Y____ Zip: _4_1__0_9_2___ Nature of Business: __l_im__e__s_t_o_n__e__m__i_n_i_n_g__o__p_e_r_a__ti_o__n_s____________________________________________________ Facility Owner/Operator: _____S__te__r_li_n_g__V__e__n_t_u_r_e_s__,_L__L_C____________________ Phone: _8__5_9_-_5__6_7__-7__3_0__0________ Email: _______________g_k_u_h_n__h_e_in__@__y_a_h_o__o_.c__o_m____________________________________________________________ Facility Contact (if different): __G__a_r_t_h__K__u_h__n_h_e__in______________________________ Phone: _8_5__9_-_6_5__3_-_2__5_5_6_________ O/O Mailing Address: __3_7__6__S__o_u__th__B__r_o_a__d_w__a__y___________________________________________________________ City: _____L_e__x_in__g_t_o_n_________________ County: _______________________________ State:__K__Y____ Zip: _4_0__5_0_8___ Well Data from File Well Name & #: ____I_N__J_E__C__T_I_O__N___W__E__L_L__#__U__IC__-_1_______________________________________________________ Well Type (see table): _C_l_a_s_s__I__(N__o_n__h_a_z__a_r_d_o_u__s__in_d__u_s_t_r_ia__l)___________ State Permit: __________________________ Latitude (N): ______3_8_._8_3_0__0_0_3___________ Longitude (W): _-_8_4_._7_5_9_7__9_4_____________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing roof of mine 484 Other: __________________________________________________________________ 10 8 no packer Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) 509to mine floor ________ Bottom(ft): ___________ Max. Injection Pressure (psig): __4_0_0____ Field Measurements and Observations Latitude (N): ____0__0_0___________________ Longitude (W): ____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: _L_i_m__e__S_t_a_b_i_l_iz_e__d__P_i_c_k_l_in_g__L__iq__u_o_r__S_l_u_d_g__e__(_L_S_W___P_L__S_)______________________ f_in__a_l_w__a_s__te__p__ro__d_u_c__t _f_ro__m__p__ic_k__li_n_g_/_c_l_e_a_n__in__g__s_te__e_l_d__u_r_in__g__s_te__e_l_m__a__n_u_f_a_c_t_u_r_i_n_g__p_r_o_c__e_s_s_.______________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values):A__u_t_h_o_r_i_z_a_t_io__n__to__i_n_j_e_c_t__w_a__s__d_a_t_e_d_,__J_a_n__u_a_r_y__2_0__, _2_0__2_2_. _T_h__e__l_a_s_t__m__e_c__h_a_n__ic__a_l_i_n_t_e__g_r_it_y__t_e_s__t_w__a_s__d__e_m__o__n_s__tr_a__te__d__o_n__J__a_n__u_a_r_y__5__,_2__0_2__1_.__________________ _N__o__w__e_l_l_r_e_m___e_d_i_a_t_i_o_n__s__n_o_r__w__e_l_l_w__o_r_k__o_v_e__r_s__h_a__v_e__b_e__e_n__c__o_n__d_u_c__te__d__f_o_r__th__e__i_n_j_e_c_t_i_o_n__w__e__ll_._____ _W__e_'_r_e__to__ld__I_n_j_e_c_t_io__n__p_r_e_s_s__u_r_e_s__t_y_p_i_c_a_l_ly__s_h_o__w__(_2_0__o__r_s_o__)_p_s__ig__c_h__a_n_g__e_s_,_w__h_i_c_h__t_h_e_y__c__a_n__s_e_e__o__n__th__e _m__o_n__it_o_r__s_c_r_e_e_n__s_._T__h_e__m__o_n__it_o_r_s__a_r_e__lo__c_a_t_e_d__i_n__a__h_u_t__a_t_t_h_e__i_n_j_e_c_t_io__n__w_e__ll_._M__a_t_e_r_i_a_l_s_f_r_o_m___th__e_______ s__te__e_l__c_o_m__p__a_n__y__a_r_e__h__a_u_l_e_d___b_y__t_r_u_c_k__s_,_w__i_t_h__a_i_r_t_a_g__s__t_o__tr_a__c_k__i_t,__p_l_a_c_e__d__i_n_t_o__b_l_a_c__k__d_u__m__p_s_t_e__rs__. _S__lu__d_g__e_s__n_e__e_d__t_o__b__e__w__e_a__th__e_r_e_d___fi_r_s_t_,_b__e_f_o_r_e__i_n_j_e_c__ti_o_n__b__e_g__in__s_._________________________________ 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._12_.1_0_1_5:_14_:4_2_-0_5_'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#: K Y S 0 7 7 0 0 0 1 Year-Month-Day: 2 0 2 4 - 1 0 - 2 3 EPA Permit # (or RA): K Y I 1 0 6 1 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______I_N__J_E__C__T_I_O__N__W___E__L_L__#__U__IC__-_1_______________C__l_a_s_s__I__(_N__o_n_h__a_z__a_r_d_o__u_s__i_n_d__u_s_t_r_i_a_l_)____________ _____________________________________________________________________________________________________ ___T_o__d_a_y_,__o_p_e__ra__to__r_e__m__a_il_e_d__Y__e_a_r__2_0__2_3__Q__u_a_r_t_e_r_l_y_M__o__n_i_to_r_i_n_g__R__e_p_o__r_ts__t_o__C_a__r_o_l_C__h_e_n__._T__h_e_s_e________ ___r_e_p__o_r_ts__s_h__o_w__e_d__i_n_j_e_c_t_io__n__a_c_t_iv_i_t_ie_s__t_h_r_o_u__g_h_o__u_t_t_h_e__y__e_a_r_._________________________________________ _____________________________________________________________________________________________________ Photo ID: DSCN1462 Time: none Lat (N): 000 Long (W) 000 _____________________________________________________________________________________________________ _D_e_s_c_r_ip_t_io_n_:__b_u__il_d__in__g__w__i_th___s_t_e_p__s__t_o__t_h__e__in__j_e_c__ti_o_n___w__e_l_l_a__n_d___s_u__m__p__p__it___________________________ _P_h_o_to__ID_:__D__S__C_N__1_4__6_3_T_im__e_: __n__o_n_e______L_a_t_(_N_)_: ______0__0_0_________L_o_n_g_(_W__) ___0__0_0___________________________ _D_e_s_c_r_ip_t_io_n_:__b_u__il_d__in__g__w__i_th___s_t_e_p__s__t_o__t_h__e__in__j_e_c__ti_o_n___w__e_l_l_a__n_d___s_u__m__p__p__it___________________________ Photo ID: DSCN1464 Time: none Lat (N): 000 Long (W) ________________________________________________________________________0_0__0__________________________ _D_e_s_c_r_ip_t_io_n_:___v__ie__w___o_f__t_h_e__i_n__je__c_t_io__n__w__e__ll___________________________________________________________ _P_h_o_t_o_I_D_:D__S__C__N__1_4_6__5_T_i_m_e_:__n__o_n_e______L_a_t_(__N_)_: _____0_0__0_________L_o_n_g_(__W_)____0_0__0__________________________ _D_e_s_c_r_ip_ti_o_n_: ____c_l_o_s__e_r__t_o__t_h__e__in__j_e_c__ti_o_n___w__e_l_l________________________________________________________ _P_h_o_to_I_D_:_D_S__C__N_1__4_6_6___T_im_e_:___n__o_n_e______L_a_t _(_N_)_: ______0_0__0_________L_on_g__(_W_)_____0_0__0__________________________ _D_e_s_c_r_ip_ti_o_n_: ______d_r_a__in__p__i_p_e__t_o___s_u_m___p__p__it____________________________________________________________ _P_h_o_t_o_I_D_:D__S_C__N_1__4_6_7__T_i_m_e_:___n_o__n_e______L_a_t _(_N_)_:______0__0_0_________L_o_n_g_(_W__)____0_0__0__________________________ _D_e_s_c_rip_t_io_n_: _i_n__s_i_d_e___c_o__n__t_r_o_l__r_o_o__m__,__v__is__ib__l_e__s__c_r_e__e_n__s__a__n__d__v__id__e__o_s__,_f_o__r__m__o__n__it_o__r_in__g___________ Photo Log Photographer:___C__a__r_o_l_C__h__e_n_______________________EPA Camera ID: ___S__C__8_2__8_4___________________________ Photo ID: _D__S__C_N__1_4__6_8_____Time: _n_o__n_e_______ Lat (N): _0_0__0_________________ Long (W) _0_0__0__________________ Description: _l_e_f_t__s_i_d_e__o__f__th__e__c__o_n__tr_o__l_r_o__o_m___________________________________________________________ Photo ID: _D__S_C__N__1__4_6__9____Time: _n_o_n__e_______ Lat (N): _0_0__0_________________ Long (W) _0_0__0__________________ Description:ri_g__h_t__s_i_d__e__o__f_t_h__e__c__o__n_t_r_o__l_r_o__o_m_________________________________________________________ Photo ID: __D_S__C__N_1__4_7_0_____Time: _n_o__n_e_______ Lat (N): _0_0__0_________________ Long (W) _0_0__0__________________ Description: m___in__e__v__i_d_e__o__a__n__d__l_o__c_a__ti_o__n__m___a_p_______________________________________________________ Photo ID: _D__S__C__N__1_4__7_1____Time: _n_o_n__e_______ Lat (N): _0_0__0_________________ Long (W) _0_0__0__________________ Description: _m__o__n__it_o__r_i_n_g___s_c__r_e_e__n__:_m___e_a__s__u_r_e__m__e__n__ts__/_p_e__r_c__e_n__t_a_g__e__s_____________________________ Photo ID: _D__S__C__N__1__4_7__2___Time: _n_o__n_e_______ Lat (N): _0_0__0_________________ Long (W) _0_0__0__________________ Description: _m__o__n_i_t_o_r_i_n_g___s_c_r_e__e_n__:__m__e_a__s_u__r_e_m___e_n__t_s_/_a_n__d__p__e_r_c_e__n__ta__g_e__s____________________________ Photo ID: _D__S__C__N__1_4_7__3____Time: _n_o__n_e_______ Lat (N): _0_0__0_________________ Long (W) _0_0__0__________________ Description: _d_r_a_i_n______________________________________________________________________________________ UIC Inspector UIC Inspector Carol Chen Name:______________________________________________ Name: ______________________________________________ Signature: _C__A_R__O__L__C__H__E__N______D_a_te_:_2_02_4_.1_2_.1_0_1_5:_15_:_07_-_0_5'_00_' _ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18