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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 0 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 3 5 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _____C_a__ro_l__C_h_e_n____________________ (lead), _____C_a__rl_a_F__o_y______________________ Start Time: 1__0_:_3_2__a_m__ ____________________________________ , _______________________________________ End Time:1__0_:_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_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 & #: ___E_._G__._J_e_f_f_r_e_y_s__#_6_-_5__________________________A_P__I _N_o__. _0_9__-1__1_3__-2__0_2_2__8____P_A__N_o__. _3_1__1_6__4_4__ 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___1__1_7__9_____________ Latitude (N): _______3_0_._9_6__8_3__4_5_________ Longitude (W): _______-8__7_._1_5__7_1_0__5______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15683' Other: ____su__rf_a_c_e_c_a_s_i_n_g_1__0_3_/_4_"__a_t_3_7_1_4__' ___________________________________ Total Depth (ft): _1_5__8_1_5__' __ Inner Casing Size (in):7_"_a_t _1_5_8_1_3'Tubing Size 3 1/2" at 15325' (in):__________ Packer Depth (ft): 1__5_2__5_5_'_ Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5_4__0_4_'_ Bottom(ft): __1_5__6_4_1__' __ 7500 N2 gas Max. Injection Pressure (psig):44__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): ____________ 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_____________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _D_A__N_G__E_R__s_i_g_n_:_H___S__M__a_y__b_e__P_r_e_s_e_n__t._._.A_u__t_h_o_r_iz_e__d_P__e_r_s_o_n_n__e_l_O__n_ly_._._.H__a_z_a_r_d_o__u_s__O_p_e__ra__ti_o_n_s__.._.K__e_e_p__O__u_t_.._._ _T_h_e__N__it_ro__g_e_n__(N___) _M__a_n_i_fo_l_d__is__n_e_a_r_b_y_,_w__it_h__a_F_l_o_w__L_i_n_e________T_u__b_in_g__G_a__u_g_e_:__________5__5_0_0__p__s_i___________ _g_a__u_g_e_.___________________________________________________P__ro__d_u_c_t_io_n__G_a__u_g_e_:______0__p__s_i _______________ __________________________________________________________S__u_r_fa__c_e_G__a_u_g_e_:_________0___p_s_i_______________ ___________________________________________________________F_lo_w__L__in_e__G_a__u_g_e_:________5_6_0__0__p_s_i___________ _____________________________________________________________________________________________________ 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:_52_:4_2_-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 7 0 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 3 5 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _________E_.__G_._J_e_f_f_r_e_y_s__#_6_-_5____________________O_G____1_1__7_9_______________A__P_I_N__o_._0__9_-_1_1__3_-_2_0_2__2_8__________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _P_h_o_to__ID__: _D_S__C_N__1_3__9_6_____T_im__e_:__1_0__:4__0__a_m_____L_a_t _(_N__):__N__o__G_P__S__0_0__0_______L_o_n_g_(__W__):___N_o__G__P_S__0__0_0_________ _D_e_s_c_r_ip_t_io__n_: ______"__T_-s_k__il_le__t_w__a_s__p_la__c_e_d__o_n__t_h_e__p_r_o_d__u_c_e_d__w__a_t_e_r_s__fl_o_w__l_in__e__to__h_a__lt__in__je_c_t_i_o_n______________ _____________________________________________________________________________________________________ Photo Log Photographer: ________C_a_r_l_a_F__o_y_______________ EPA Camera ID:_____________S__C_8__2_8_4_________________________ Photo ID: ___D_S__C_N__1_3__9_0____Time: _1__0_:_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: _i_n_j_e_c_t_io__n_w__e_l_l,__id_e__n_t_if_i_c_a_t_io__n_s__ig_n__, _D_A__N_G__E_R__s_i_g_n_:__H___S__M__a_y__b_e__P_r_e_s_e_n__t._._.K__e_e_p__O__u_t_.._.________ Photo ID: ___D_S__C_N__1_3_9__1____Time: 1__0_:_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: __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_9__2____Time: _1_0_:_3_7__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_fa__c_e__g_a_u_g_e__r_e_a__d_s__0__p_s_i________________________________________________________________ Photo ID: __D__S_C__N_1__3_9__3____Time: _1_0_:_3_7__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__g_a__u_g_e__r_e_a_d__s_0__p__s_i ____________________________________________________________ Photo ID: __D__S_C_N__1_3__9_4_____Time: _1_0_:_3_8_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_t_u_b__in__g_g__a_u_g_e__r_e_a__d_s__5_5_0__0__p_s_i____________________________________________________ Photo ID: __D__S_C_N__1_3__9_5_____Time: 1__0_:3__8_a__m____ Lat (N): __N__o_G__P_S__0__0_0________ Long (W) _N_o__G__P_S__0_0__0__________ Description: _F__lo_w___L_in__e_g__a_u_g_e__o__n_t_h_e__n__e_a_r_b_y__N_i_t_r_o_g_e_n__g_a__s_m__a__n_if_o_l_d__r_e_a_d_s__5__6_0_0__p__s_i____________________ 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_2_4._06_.2_0_2_1:_53_:0_9_-0_4_'0_0'___ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18