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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 Phone: (404)562-9424 EPA Well ID#: F L S 1 1 3 0 0 4 9 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 3 Page 1 Of 2 Inspector(s): _____C__a_r_o_l _C_h_e_n____________________ (lead), _______C_a_r_la__F_o_y_____________________ Start Time: _2__:3__5__p_m__ ____________________________________ , _______________________________________ End Time: _2_:_3_7__p__m__ Facility Contact Information Well Data from File 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_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__ St. Regis Paper Company (SRPC) SWD #9-3 API No. 09-113-20195 PA No. 311640 Well Name & #: ________________________________________________________________________________________ Well Type (see table): __P_r_o_d_u__c_e_d__W__a_t_e_r__D_i_s_p_o_s__a_l_(_P_W__D__) ____________ State Permit: _______O_G____1_0__4_7___________ Latitude (N): _________3_0_._9_5_5_2_7_8_________ Longitude (W): _________-_8_7_._1_9_5_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 6785' Other: _____s_u_rf_a_c_e__ca__si_n_g_1__0_3__/4__" _a_t_3_7_3_5__' __________________________________ Total Depth (ft): _1__0_4__2_3_'__ Inner Casing Size (in): 7_"_______ Tubing Size (in):4__1__/_2_"____ Packer Depth (ft): __6_1__0_9__' Inj. Zone: Open Hole; X Perforated; Top(ft) __6_4_0__0_'_ Bottom(ft): ___6__6_0_0__' __ Max. Injection Pressure (psig): 1_8__0_0__p_s_i Latitude (N): ______3__0_._9_5__5_5_7__8_________ Longitude (W): _____-8__7_._1_7__8_1__9_1________ Elevation (ft): ____________ EPA GPS ID: S__7_5__3_3_2__ Well Status (see table): ____S_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): ______________________________________________________ DANGER sign posted: HS May Be Present..Authorized Personnel Only..Hazardous Operations... _____________________________________________________________________________________________________ _S_i_g_n__is__p_o__s_t_e_d__s_h_o_w__in__g__w_e_l_l_i_d_e_n__ti_f_ic_a__ti_o_n_._________________T__u_b_in__g_g_a_u__g_e_:________0__p__s_i ________________ _T_h__is__w_e__ll_i_s__s_h_u_t_-_in__. ________________________________________P_r_o_d_u_c_t_io_n__g_a_u__g_e_:____0__p__s_i________________ _A__p_r_o_d_u__c_e_r_i_s__o_n__t_h_e__s_a_m__e__l_e_a_s_e_:___________________________S_u_r_f_a_c_e_g__a_u_g_e_:_______0__p__s_i ________________ _S_t_R__e_g_i_s__P_a_p__e_r_C__o_m__p_a_n__y_(_S_R__P_C__) _#_9__-5__A_____________________F_lo_w__l_in__e_g_a__u_g_e_:___________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Field Measurements and Observations 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:_37_:1_1_-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 4 9 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 3 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______S__t.__R_e_g__is__P_a_p__e_r_C__o_m__p_a_n__y_S__W__D__#_9__-3_____________O_G____1_0__4_7____________A_P_I__N_o__. _0_9__-1__1_3_-_2_0__1_9__5____ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen S75332 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: ____R__IM__G__0_1__4_8___Time: __2_:_3_6__p__m___ Lat (N): ____3__0_._9_5_5__5_7__8______ Long (W) _____-_8_7__.1__7_8__1_9_1______ Production gauge. Description: ___________________________________________________________________________________________ Photo ID: ____R_I_M__G__0_1_4__9___Time: __2_:_3_6__p__m___ Lat (N): ____3_0__.9__5_5__6_5_3_______ Long (W) _____-_8_7__.1__7_8__1_9_6______ Description: __P_r_o__d_u_c_t_i_o_n__g_a_u_g__e_._______________________________________________________________________ Photo ID: ____R_I_M__G_0__1_5_0____Time: __2_:_3_7__p__m___ Lat (N): ____3_0__.9__5_5_6__8_6_______ Long (W) ______-8__7_._1_7_8__2_1__3_____ Photo of the injection well. Description: ___________________________________________________________________________________________ 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_.0_6_.20_2_1_:3_7:_37_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18