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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program EPA Well ID#: F L S 1 1 3 0 0 2 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 EPA Permit # (or RA): 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: _2__:4__7__p_m__ ____________________________________ , _______________________________________ End Time: _2_:_4_9__p__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________________________________________________________ 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 Field Measurements and Observations Well Name & #: ____A_L__IC__E_B__R_A__Y_#__2_0__-3___________________A_P__I _N_o__. _0_9__1_1_3__2_0__0_8__0_______P_A__N__o_._3__1_1__5_9_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____5__9_1______________ Latitude (N): ________3_0_._9_4__3_9__7_7________ Longitude (W): ______-8__7_._1_8__3_5_4__8_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBDT: 15944' Other: __s__u_r_fa__c_e__c_a_s_i_n_g__9__5_/_8__"_a_t__3__8_0__7_'________________________________ Total Depth (ft): _1__6_0__3_6_'__ 7" at 16009' 3 1/2" at 15480' Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): _1_5_4_8_0_'__ Inj. Zone: Open Hole; X Perforated; Top(ft) 1__5_6_7__5_'_ Bottom(ft): _1__5_7__7_5_'___ 7500 N2 gas Max. Injection Pressure (psig):4_4_0_0_p_s_i_P_W 30.944015 -87.183488 Latitude (N): __________________________ Longitude (W): ________________________ Elevation (ft): ____________ EPA GPS ID: _S_7_5__3_3__2_ Well Status (see table): ___A__C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _____P_r_o_d_u__c_e_d_W__a_t_e_r_s__(P_W__)_________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _D_A_N__G_E__R__s_ig__n__is__p_o_s_t_e_d__: _H__S__M__a__y_B__e_P__re__s_e_n_t_._.A__u_t_h_o_r_iz_e__d__P_e_r_s_o_n__n_e_l_O__n_l_y_.._H_a__z_a_r_d_o_u_s__O__p_e_r_a_t_io__n_s_._..____ _A_n__id__e_n_t_if_i_c_a_t_io__n__s_ig_n__w__a_s__p_o_s_t_e_d__o_n__s_i_t_e__fo__r_t_h_e_____________T_u_b_i_n_g__g_a_u__g_e_:__________4__0_0__p_s__i __________ _in__je_c__ti_o_n__w__e_ll_.______________________________________________P_r_o_d__u_c_t_io__n__g_a_u_g_e__: _____0__p__s_i _____________ _T_h__is__w_e__ll_i_s__a_c_t_iv__e_ly__in__je__c_ti_n_g__p_r_o_d__u_c_e_d__f_l_u_id__s_.______________S_u__r_fa__c_e_g__a_u_g_e__: ________0__p__s_i_____________ ____________________________________________________________F_l_o_w__li_n_e__g_a_u_g_e_:___________________________ _____________________________________________________________________________________________________ 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:_27_:5_7_-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 2 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ALICE BRAY #20-3 State Permit No. OG_591 API No. 0911320080 _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen Photographer: ______________________________________EPA Camera ID: __________S__7_5_3__3_2_____________________ Photo ID: ___R_I_M__G__0_1_5__1____Time: __2__:4__7__p_m___ Lat (N): _____3_0__.9_4__4_0_1__8______ Long (W) ______-8__7_.1__8_3_4__5_7______ Description: _in_j_e_c_t_io_n__w_e__ll_, _w_e_l_l _id_e__n_ti_f_ic_a_t_io__n_s_i_g_n__a_n_d__D_A_N__G_E_R__s_i_g_n_p__o_s_te__d_: _H__S__M__a_y_B__e_P_r_e_s_e_n__t...__H_a__za__rd_o__u_s_.._._ Photo ID: ___R__IM__G__0_1__5_2____Time: __2__:4__8__p_m___ Lat (N): _____3_0__.9_4__4_0_1__5______ Long (W) ______-8__7_.1__8_3_4__8_8______ Description: _s_u_r_f_a_c_e__g_a_u_g_e__r_e_a_d_s__0_p__s_i __________________________________________________________________ Photo ID: ___R__IM__G__0_1__5_3____Time: __2__:4__8__p_m___ Lat (N): _____3_0_._9_4__4_0_1_7_______ Long (W) _____-_8_7__.1_8__3_4_________ Description: _t_u_b_i_n_g__in_j_e_c_t_io_n__g_a_u__g_e_r_e_a__d_s_4__0_0__p_s_i________________________________________________________ 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 Name:______C_a__ro_l__C_h_e_n________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.0_6_.20_2_1_:2_8:_22_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18