Document 7Mpgrz7ddb3rLMb8m1evrq9qB
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 0 3 3 0 0 0 1 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_la__F_o_y_______________________ Start Time: _1_0_:_5_3__a__m_
11:01 am
____________________________________ , _______________________________________ End Time: __________
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__ra__ti_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: ___E__s_c_a_m__b_i_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: ____E__s_c_a_m__b_i_a__________________ State:__F_L_____ Zip: __3_2__5_6_5__
Well Data from File
Well Name & #: __M__c_D_a__v_id__L_a__n_d_s__#_2__-2______________A_P__I_N__o_._0_9__0_3__3_2__0_0_0__9_________P__A__N_o_.__3__1_1_5__8_0________ Well Type (see table): ____E_n_h_a__n_c_e_d__O__il__R_e_c_o__v_e_r_y_(_E_O__R_)______________ State Permit: _______O__G____4_9_2____________ Latitude (N): ______3_0__.9__8_1_3__8_9__________ Longitude (W): _____-_8_7_._2_1__3_0__5_6________ Elevation (ft): ____________
Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing
PBTD: 15,747'
6 sets of perforations/Smackover
Other: __s_u_r_f_a_c_e__c_a_s__in_g__1__3__3_/_8__" _t_o__1_,_1_3_9__' ___c_o_n__d_u_c_t_o_r__p_i_p_e__1_6__"_@__1_1__1_'__
Total Depth (ft): 1__5_,_9_0_7__' __ Inner Casing Size (in): 8__3__/_4_"__ Tubing Size (in):_3__1__/_2_"___ Packer Depth (ft): _1__5_,_6_7_6_ '
Inj. Zone: Open Hole; XPerforated; Top(ft) 1_5__,4__9_7_'_ Bottom(ft):
_1_5_,_6_5__6_'___
7,500psi N2 Max. Injection Pressure (psig): 4_,_4_0_0_p_si_P_W
Latitude (N): ______3_0__.9__8_1_3__9_8__________
-87.212921
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__te_r_s__(P__W_)__________________________________________________
Field Measurements and Observations
General Condition of the Well Site: _________________________________________________________________________
_____________________________________________________________________________________________________
Notes & Comments (include discrepancies from database values): __D_a_n__g_e_r_s_i_g_n_p__o_s_te__d_o__n_t_h_e__m__e_ta__ll_ic__fr_a_m__e_w__o_r_k_a_r_o_u__n_d___ th__e_i_n_j_e_c_ti_o_n__w_e_l_l:__H__S__M__a_y_B_e__P_r_e_s_e_n__t._.._A_u_t_h_o_r_i_z_e_d_P__e_r_s_o_n_n_e_l_O__n_ly_._.._H_a__z_a_rd__o_u_s__O_p_e_r_a_t_io__n_s_.._.K__e_e_p__O_u_t_._..______
_O_n__s_it_e_,_t_h_e__in_j_e_c_t_io_n__p_u__m_p__c_o_u_l_d__b_e__h_e_a_r_d_,_p_u__m_p_i_n_g__lo_u__d_ly_._____________T_u_b_in_g__g_a_u_g_e_:_______3_0_0__0_p__s_i _______ _O_n__t_h_e__in_j_e_c_t_io_n__w__e_ll_,_t_h_e___"__T_-_s_k_il_le_t__w_a_s__p_la__c_e_d__th_e__re__t_o_b__lo_c_k__t_h_e______P_r_o_d_u_c_t_io_n__g_a_u_g_e_: ___0__p_s_i___________ _N__it_ro__g_e_n__(N___) _fl_o_w__li_n_e_._P_r_o_d_u__c_e_d_W__a_t_e_r_s__(P_W__)_w__e_r_e__fl_o_w_i_n_g__th__ro_u__g_h______S_u_r_f_a_c_e_g_a_u_g_e_:______0__p_s_i___________ _t_h_e__h_o_t_i_n_j_e_c_t_io_n__li_n_e_.________________________________________________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_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:_18_: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 0 1 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0
EPA Permit # (or RA):
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(Cont) ________________________________________________________________________________________________
______M__c_D__a_v_i_d__L_a_n_d__s_#__2_-_2___________________________________________________________________________
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Photo Log
Carol Chen
S75332
Photographer:______________________________________EPA Camera ID: ______________________________________
Photo ID: ___R__IM__G__0_1_1__4____Time: __1_0__:5__4__a_m__ Lat (N): _____3__0_._9_8__1_4_4__8_____ Long (W) _____-_8_7__.2__1_3__0_2_2______
Description: DANGER sign posted on the injection well: HS May Be Present..Hazardous Operations... Photo ID: ___R__IM__G__0_1_1__5____Time: __1__0_:_5_4__a_m__ Lat (N): _____3__0_._9_8__1_4_1__1_____ Long (W) _____-_8_7__.2__1_2__9_4_______
tubing gauge
Description: ___________________________________________________________________________________________
Photo ID: ___R__IM__G__0_1__1_6____Time: __1__0_:_5_6__a__m_ Lat (N): _____3__0_._9_8_1__3_9__8_____ Long (W) _____-_8_7__.2__1_2_9__2_1______ Description: ______"__T_-s_k_i_ll_e_t_b_l_o_c_k_s__N_i_tr_o_g_e__n_(_N__)__fl_o_w__l_in_e__________________________________________________ Photo ID: ____R_I_M__G_0__1_1_7____Time: ___1_0_:_5_8__a__m_ Lat (N): _____3__0_._9_8__1_4________ Long (W) _____-_8_7__.2__1_2_7__9_3______
Description: _____P_r_o_d_u_c_e__d_W__a_t_e_r_s_(_P_W__)_f_l_o_w_l_in_e___________________________________________________________ Photo ID: ____R_I_M__G_0__1_1_8____Time: ___1_1__:0__1__a_m_ Lat (N): ______3_0_._9_8__1_3__9______ Long (W) _____-8__7_._2_1__2_9__4_3______ Description: y_e_l_l_o_w__a_n_n_u_l_a_r_p__re_s_s__u_re__g_a_u__g_e_a__n_d_s_i_l_v_e_r_p_a_n_e__l _w_i_th__s_h_u__t _o_f_f/_o_n__s_w__it_c_h_e_s__fo__r_P_W__a__n_d__N___in_j_e_c_t_i_o_n_
Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________
Description: ___________________________________________________________________________________________
UIC Inspector
UIC Inspector
Name:________C_a_r_o_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_:19_:2_5_-0_4_'00_' ____ Signature: ___________________________________________ Digitally signed by CAROL CHEN
Version 2018-04-18