Document 6RVLjEvzp9rodZnN7rvj4Vmwd

Inspection ID Class V General 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 V 1 1 1 0 5 8 1 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): R A Page 1 Of 2 Inspector(s): ______C__a_r_l_E_.__W__e_l_le_r______________ (lead),_______C_a__ro__l_C_h__e_n_________________ Start Time: _5_:_0_3__p_m___ ____________________________________, ____________________________________ End Time: _5_:_0_4__p__m__ Facility Contact Information Transit Authority of River City (TARC) Facility Name: __________________________________________________________________________________________ Street Address:____1__0_0_0__W__e__s_t_B__ro__a_d_w__a_y________________________________________________________________ City: _____L__o_u_i_s_v_il_l_e_________________ County: __________J_e_f_fe__rs__o_n_____________ State:___K__Y___ Zip: _4__0_2__0_3__ Nature of Business: ____T_r_a_n__s_p_o_r_t_a_t_i_o_n__&__L_o__g_is__ti_c_s__-__P_u_b__li_c__T_r_a_n_s_p__o_r_ta__t_io_n_______________________________ Facility Owner/Operator: _____T_r_a__n_s_i_t _A_u__th__o_r_it_y__o_f_R__i_v_e_r_C__it_y__(T__A_R__C_)_______ Phone: ____5_0_2__.2__1_3__.3__4_8_1_______ Email: ___d_o_w__e_n_s__@_r_i_d_e_t_a_r_c_._o_r_g___c_w__a_r_d_@__r_id__e_t_a_r_c_.c__o_m___C__h_r_is__W__a_r_d_,__D_i_r_e_c_t_o_r_o__f_C_a__p_i_ta__l_a_n__d_F__a_c_i_li_t_ie_s____ Facility Contact (if different): _D__a_v_i_d__O_w__e_n__s_,_1_0__t_h_S__t_re__e_t_D__iv__is_i_o_n__S_u__p_e_r_v_i_s_o_r_ Phone: ____5_0__2_-_2_1__3_-_3_2_1__8______ O/O Mailing Address: _____1_0__0_0__W__e__s_t_B_r_o__a_d_w__a_y__________________________________________________________ City: _____L_o_u_i_s_v_i_ll_e__________________ County: _________J_e_f_f_e_r_s_o_n______________ State:___K__Y___ Zip: _4__0_2_0__3__ Well Data from File Storm Water Drainage # 1 Well Name & #: ________________________________________________________________________________________ Well Type (see table): _____T_y_p_e__2_:__s_to__rm___w__a_t_e_r__d_r_a_i_n_a_g_e_____________ State Permit: __________________________ Latitude (N): ______3_8__.2__4_4_6__2_5__0_0_______ Longitude (W): _____-_8_5__.7__6_8_4__5_2__7_8_____ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Improved Sinkhole; Tubing & Packer; Drain Field/Septic Tank Infiltration Gallery; XOther: ___s_t_o_r_m___w__a_t_e_r_i_n_f_i_lt_r_a_t_io__n__in_j_e_c_t_i_o_n_____________ Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ________3_8__.2__4_4__6_5_________ Longitude (W): ______-8__5_._7_6__8_6_2_________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): ____A_C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: ___s_t_o_r_m___w_a__te__r_r_u_n__-o_f_f____________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _________________________________________________________________________ Tubing PSI: ______________ Pump PSI: _______________ Annulus PSI: _____________ Annulus Fluid:_______________ Notes & Comments (Include Discrepancies from database values):__Im__p__ro__v_e_d__s_i_n_k_h__o_le__, _d_r_y__w_e__ll_, _w__it_h__r_ip__r_a_p__c_h__a_n_n_e__l___ _E_a_c__h_w__e_l_l_h_a__s_H__ig__h_-_d_e_n_s_i_t_y_P__o_l_y_e_t_h_y_l_e_n_e__(_H_D__P_E__) _p_i_p_e_,_2__4_"__d_i_a_m__e_t_e_r_,_t_w__e_lv_e__(_1_2__)_f_e_e_t__d_e_p__th__________ _w_i_t_h__2_4__"_m__e_t_a_l_l_ic__c_a_p__(_b_e_e__h_iv__e_g__ra__te__)_a_t__th__e__to__p_(_s_u_r_f_a_c_e__),__fi_ll_e_d__w__it_h__c_r_u_s_h__e_d__s_t_o_n_e_._________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC InspeOctwonr er/OpeUUraIICCtoIIrnnRssppeeepccrtetoosrrentative (Optional) UIC Inspector Carl E. Weller Carol Chen Name:_______________________________________________ Name: ______________________________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3._09_.1_4 0_8_:29_:2_6 _-04_'0_0'______ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O__L__C_H__E__N_______D_a_te_: _20_2_3._09_.1_3_1_9:_07_:3_6_-0_4_'0_0'___ Digitally signed by CAROL CHEN Version 2018-04-18 Inspection ID Field Measurements and Observations (Cont.) Class V General Well Inspection Form EPA Well ID#: K Y V 1 1 1 0 5 8 1 US Environmental Protection Agency - Region 4 Underground Injection Control Program 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 Phone: (404)562-9424 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): R A Page 2 Of 2 _K_Y_V__1_1_1_0__5_8_1__S_t_o_r_m__W__a__te_r__D_r_a_i_n_a_g_e__W__e_l_l _#_1___________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:__________C__a_r_l _E_._W__e__ll_e_r_______________EPA Camera ID: _______S_X_8__1_2__3________________________ Photo ID: _____2_5_8__________Time: ___4_:_1_7_p__m___ Lat (N): _____3_8_.2__4_4_6_4_1________ Long (W) ______-8_5_._7_6_8_7__5_5_______ Description: ____v_i_e_w_o__f _th_e__r_e_te_n_t_i_o_n_p_o_n_d__, _in_f_il_tr_a_t_io_n__b_a_s_i_n_, _fa_c_i_n_g_e_a_s_t________________________________________ Photo ID: _____2_5__9_________Time: ___4_:_1_7_p_m____ Lat (N): _____3_8_._2_4_4_7_3_6________ Long (W) ______-8_5__.7_6_8__4_9________ Description: ____v_i_e_w__o_f _re_t_e_n_t_io_n__p_o_n_d_,_f_a_c_in__g_s_o_u_t_h_________________________________________________________ Photo ID: _____2__6_0_________Time: ___4_:_5_4__p_m___ Lat (N): _____3_8__.2_4_4__6_7________ Long (W) ______-_8_5_._7_6_8_3_9________ Description: _____o_v_e_rf_lo_w__u_n__it____________________________________________________________________________ Photo ID: _________________Time: ___5_:0__3_p_m____ Lat (N): ____3__8_.2_4__4_6_5_________ Long (W) ______-_8_5_._7_6_8_6_2________ KYV1110581 Storm Water Drainage Well #1 Description: ___________________________________________________________________________________________ Photo ID: _____2_6_5__________Time: ___5_:0__4_p_m____ Lat (N): _____3_8_.2__4_4_6_7_________ Long (W) ______-_8_5_._7_6_8_7_1________ Description: _____i_n_le_t_v_e_n_t_f_r_o_m__c_o_n_c_r_e_te__p_a_r_k_in_g__a_r_e_a_1__0_"___________________________________________________ Photo ID: _____2_6_6__________Time: ___5_:_0_6_p_m____ Lat (N): ____3_8_._2_4_4_4_6__9________ Long (W) ______-_8_5_._7_6_8_7_1________ Description: ______in_f_il_tr_a_t_io_n__d_r_a_in__c_u_lv_e_r_t_, _o_v_e_rf_lo_w__g_r_a_t_e_1_8__"_x_3_6__"____________________________________________ UIC InspeOcwtonrer/OpeUrIaCtoIUnrIsCRpeIenpcsrteposerecntotar tive (Optional) UIC Inspector Name:___________C_a__r_l _E_._W__e__ll_e_r_______________________ Carol Chen Name: ______________________________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3_.09_.1_4_08_:3_0:_03_-0_4_'00_' _____ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_23_.0_9_.13_1_9_:0_8:_27_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18