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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#: K Y S 0 9 9 0 0 0 4 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 EPA Permit # (or RA): K Y I 0 3 8 9 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _C__a_r_o_l__C__h_e__n____________________ (lead),_____L_o__n_n__ie___D_o__r_n________________ Start Time: _8_:_3_4__a__m__ ____________________________________, ____________________________________ End Time: 8__:_4_0__a__m__ Facility Contact Information Facility Name:______L__o_g_s_d__o_n__V__a_l_le_y__O__i_l _C__o_.,__In__c_._______________________________________________________ Street Address:_____1_0__5__B_e__d_fo__r_d__C_o__u_r_t_________________________________________________________________ City: ____H__o_r_s_e___C_a__v_e_______________ County: __________H__a_r_t_________________ State:_K_Y______ Zip: _4_2__7_4__9__ Nature of Business: ________________o_i_l_p__r_o_d_u__c_t_io__n_______________________________________________________ Facility Owner/Operator: ____M__s__._E__ll_e_n__S__t_in__s_o__n_,__P_r_e__s_id__e_n__t_____________ Phone: _2_7_0__-5_3__7_-_4_2_8_8___________ Email: ____e_s_t_i_n_s_o__n_@___s_c__rt_c_._c_o__m_______________________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: ________________________ O/O Mailing Address: _____1__0_5__B_e__d_f_o_r_d__C__o_u_r_t____________________________________________________________ City: _____H__o_r_s_e__C__a_v_e_______________ County: ________H_a__r_t___________________ State:__K__Y____ Zip: _4_2__7_4_9___ Well Data from File Well Name & #: _____G__U__IN__N___#_U__A__-_3____________________________________________________________________ Well Type (see table): _C__la__s_s__II_-_R__, _E_n__h_a_n__c_e_d__O__i_l _R__e_c_o_v__e_r_y__(E__O__R_)__ State Permit: ____7_7__8_0_4_________________ Latitude (N): ______3_7_._1_7__5_3_4_1___________ Longitude (W): _____-8__5_.7__8_9_2_3_6__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing Other: __________________________________________________________________ Total Depth (ft): ___6_2__7____ Inner Casing Size (in): _4_____"__ Tubing Size (in):__2_____"___ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ 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): __T__A_____ If not Active, Reported Date Last Active: _3_/_1_7__/2__0_1_6________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _T_a__n_k__t_ru__c_k__w_i_t_h__h_o_i_s_t_in_g__a__n_d__r_ig__g_i_n_g__e_q__u_ip__m__e_n_t_,_h__e_l_d_o__v_e_r__th__e__in__je_c__ti_o_n__w__e_l_l.______________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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_4.1_2_.1_0_17_:2_4_:4_4_-0_5'_00_' ___ 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 9 9 0 0 Year-Month-Day: 2 0 2 4 - 1 0 - EPA Permit # (or RA): K Y I 0 3 Page 2 Of 04 24 89 2 (Cont) ________________________________________________________________________________________________ ____________G__U___IN___N___#_U__A__-_3_________C__la__s_s__I_I_-R__,__E_n__h_a__n_c_e__d__O__i_l _R__e_c_o__v_e__ry__(_E__O__R__)________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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_5_0__9_____Time: _8_:_3__4__a__m___ Lat (N): _____0_0__0_____________ Long (W) _____0_0__0______________ Description: _in__je__c_t_i_o_n__w__e__l_l ___________________________________________________________________________ Photo ID: _D_S__C__N_1_5__1_0______Time: _8_:_3_4___a_m____ Lat (N): _____0_0_0______________ Long (W) ____0__0_0_______________ Description: _s_t_o__r_a_g__e__t_a__n__k___________________________________________________________________________ Photo ID: _D__S_C__N__1_5_1__1_____Time: _8_:_3_5__a__m____ Lat (N): _____0_0__0_____________ Long (W) _____0_0__0______________ Description: _ta__n__k__t_r_u__c_k_______________________________________________________________________________ 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 Carol Chen Name:______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.1_2_.10_1_7_:2_5:_08_-0_5_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18