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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 1 7 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 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: _4_:_1_0__p_m___ ____________________________________, ____________________________________ End Time: _4_:_1_5__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_____(_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 Field Measurements and Observations Rosie L. Kersey #10-3 API No. 0911320040 PA No. 311588 Well Name & #: ________________________________________________________________________________________ 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_2_2_____________ Latitude (N): _____3_0__.9__4_0__7_2_2___________ Longitude (W): _______-8__7_._1_5__0_9__4_4______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing PBTD: 15,754' 5 sets perforations Smackover Other: ___s_u_r_f_a_c_e__c_a__s_in__g__1_0__3__/_4_"__to__3__,6__7_8_'______________________________ Total Depth (ft): 1__5_,_8_1_1__' __ Inner Casing Size (in): 8__3_/__4_"__ Tubing Size (in):__3__1_/_2__"__ Packer Depth (ft): _1_5_,_1_1__3_' Inj. Zone: Open Hole; X Perforated; Top(ft) 1_5__,4__6_9__' Bottom(ft): _1_5__,6__4_6__' __ 7,500 N2 gas 4400psi PW Max. Injection Pressure (psig): ________ ' Latitude (N): _____3_0__.9__5_8__3_0_3___________ Longitude (W): ______-8__7_._1_6_6__6_2__7_______ 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: _____N__i_tr_o_g__e_n__(N___)__G_a_s__I_n_j_e_c_t_i_o_n__________________________________________ 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_...__H_a_z_a__rd__o_u_s__O_p__e_r_a_t_io_n__s_.._._K_e_e__p_O__u_t_._.._H_o__t _P_i_p_i_n_g_._.._________________ _T_h__is__w_e__ll_i_s__a_c_t_iv__e_ly__in__je__c_ti_n_g__N__it_r_o_g_e_n__(_N___)_g_a_s__. ____________T_u__b_in__g__g_a_u_g_e__:__________5_3__0_0__p_s__i ________ ____________________________________________________________P_r_o__d_u_c_t_i_o_n__g_a_u_g__e_:______0__p_s_i_____________ ____________________________________________________________S_u__rf_a_c__e_g__a_u_g_e__: _________0__p_s_i_____________ ____________________________________________________________F_l_o_w__L_i_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:_25_:3_6_-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 1 7 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _____R_o__s_ie__L_.__K_e_r_s_e__y_#__1_0_-_3________A_P_I_N__o_._0__9_1__1_3_2__0_0__4_0_______________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _______C_a_r_o_l__C_h_e__n_____________________EPA Camera ID: S75332 ______________________________________ Photo ID: ___R_I_M__G_0__1_7__1____Time: __4_:_0_7__p__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_i_d_e_n_t_i_fi_c_a_t_i_o_n__s_i_g_n__a_t_t_h_e__f_r_o_n_t__o_f_t_h_e__p_r_o_p__e_r_t_y_______________________________ Photo ID: __R__I_M_G__0_1__7_2_____Time: __4_:_1_0__p__m___ Lat (N): ____3_0_._9_5__8_2__2_3_______ Long (W) ____-_8_7__.1__6_6__6_1_8_______ 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__re__s_e_n_t_._.._K_e__e_p__O_u__t._._. ________ Photo ID: ___R_I_M__G__0_1_7__3____Time: __4_:_1_1__p__m___ Lat (N): ____3_0__.9__5_8_3__0_6_______ Long (W) ____-_8_7__.1__6_6_6__1_2_______ production gauge reads 0 psi Description: ___________________________________________________________________________________________ Photo ID: ___R__IM__G__0_1__7_4____Time: __4__:1__1__p_m___ Lat (N): ____3_0__.9__5_8_3__0_3_______ Long (W) ____-_8_7__.1__6_6__6_2_7_______ Description: __n_e_a_r__b_a_s_e__o__f _in__je__c_ti_o_n__w__e_l_l _______________________________________________________________ Photo ID: ___R__I_M_G__0_1__7_5____Time: __4_:_1_2__p_m____ Lat (N): ____3_0_._9_5__8_3__2_8_______ Long (W) ____-_8_7__.1__6_6__6_6_4_______ Description: _i_n_j_e_c_t_i_o_n__tu__b_i_n_g__g_a_u_g__e_r_e__a_d_s__5_3__0_0__p_s_i____________________________________________________ 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_:26_:0_2_-0_4_'00_' ____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18