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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#: K Y S 0 9 1 0 1 2 1 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 Page 1 Of 2 Inspector(s): ______C_a_r_l_E__._W__e_l_l_e_r______________ (lead),______C_a_r_o__l _C_h_e__n__________________ Start Time: _1_1_:_1_1__a_m__ ____________________________________, ____________________________________ End Time: 1__1_:1__1__a_m__ Facility Contact Information Facility Name:_____W__e__s_t_K__e_n_t_u_c_k__y_E__n_e_r_g_y__R__e_s_o_u_r_c_e__s_,_L_L_C_______________________________________________ Street Address:_____3_8__3_0__V_i_n_c_e__n_t_S__ta__ti_o_n__D__r_iv_e__________________________________________________________ City: _____O__w__e_n_s_b__o_r_o_______________ County: ______H__a_n_c_o__c_k_________________ State:___K__Y___ Zip: _4__2_3__0_3__ Nature of Business: _____O__il__a_n_d__g_a__s_e__x_tr_a__c_ti_o_n___________________________________________________________ Facility Owner/Operator: ____W__e_s_t__K_e_n__t_u_c_k_y__E_n__e_r_g_y_R__e_s_o__u_r_c_e_s_,_L__L_C_______ Phone: ____2__7_0__-9__2_6_-_1_6__8_9______ Email: ___________________G__le__n_n__R_i_d_g__e_s_:__2_7_0__-3__1_6__-7__4_8__7_______________________________________________ Facility Contact (if different): ____M_r_._V__in__c_e_n_t__B_._H__a_y_d__e_n_,_J_r_._, _M__a_n_a__g_e_r_________ Phone: _____2_7__0_-_6_8_3__-3__0_5__7_____ O/O Mailing Address: _____3_8_3__0__V_i_n_c_e_n__t_S_t_a__ti_o_n__D__ri_v_e_____________________________________________________ City: ______O_w__e_n_s_b__o_r_o_______________ County: ______H_a__n_c_o_c_k__________________ State:___K_Y____ Zip: __4_2_3__0_3__ Well Data from File Field Measurements and Observations Well Name & #: ______M__a_r_y_M__a_d_d_e__n_-R__ic_h__a_rd__s_#__W_-_6________________________________________________________ Well Type (see table): ______E_n__h_a_n_c__e_d__O_i_l_R__e_c_o_v_e__ry__(_E_O__R_)___________ State Permit: __________________________ Latitude (N): _____3__7_._7_0_4__2_5____________ Longitude (W): _____-8__6_._7_1_6__6_3__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: Other: __________________________________________________________________ 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): ________ Latitude (N): ______3__7_._7_0_4__1_9___________ Longitude (W): _____-_8_6__.7__1_6__7_8_________ Elevation (ft): ____________ EPA GPS ID: _S_X__8_1_2_3__ Well Status (see table): ___A_B_____ If not Active, Reported Date Last Active: __1_2__/_0_5__/_1_9__9_0____ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ___W__e_l_l_s_a__re__l_o_c_a__te__d__in__R__e_y_n_o_l_d_s__S_t_a__ti_o_n_,__K_Y__4_2__3_6__8__ _T_a__n_k__b_a_t_t_e_r_y__is__d_i_s_c_o_n__n_e_c_t_e_d__f_r_o_m___in__je__c_ti_o_n__l_in__e_s_._T_h__is__w__e_l_l _is__a_m__o__n_g__t_a_l_l _c_o_r_n__f_ie_l_d_s__-_n__o_t_v_i_s_i_b_le__. __ _I_n_s_p__e_c_t_o_r_s__a_r_e__s_ta__n_d_i_n_g__a_t__t_h_e__e_d_g__e_o__f_t_h_e__c_o_r_n__f_ie__ld__s_, _t_a_k_i_n_g__p_h__o_t_o_s_.______________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Carl E. Weller Name:______________________________________________ Carol Chen Name: ______________________________________________ Digitally signed by CARL WELLER (Affiliate) Signature:_C_A_R__L_W__E_L_L_E__R_(_A_f_fi_li_a_te_)_D_a_te_: 2_02_3._09_.0_1 1_6_:29_:3_4_-0_4'0_0'______ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_3._08_.3_1_1_6:_11_:3_2_-0_4_'0_0'___ 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#: K Y S 0 9 1 0 1 2 1 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 Page 2 Of 2 (Cont) ___K__Y_S_0__9_1_0_1__2_1_____M_a__ry__M__a_d_d_e_n__-R_i_c_h_a_r_d_s__#_W__-_6__________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_____C__a_r_l _E_._W__e_l_le_r_____________________EPA Camera ID: _____S__X_8_1_2__3__________________________ Photo ID: ____2__3_4__________Time: _1__0_:_3_5__a_m___ Lat (N): ___3__7_._7_0__7_8_1__2_______ Long (W) ___-_8_6_._7_1__9_4__3_9________ Description: ________o_p_e_r_a__to__r'_s__s_ig__n_o__n__p_r_o_p_e__rt_y_________________________________________________________ Photo ID: _____2_3__5_________Time: __1_0_:_3_5__a__m__ Lat (N): ___3__7_._7_0__7_8_0__9_______ Long (W) ___-_8_6__.7__1_9__4_4_8________ Description: ________t_a_n_k__b_a__tt_e_r_y__a_n__d_s_i_g_n_______________________________________________________________ Photo ID: _____2_4__2_________Time: __1_1_:_1_1__a__m__ Lat (N): ___3__7_._7_0_4__4_8__6_______ Long (W) ____-8__6_._7_1_5__0_6__7_______ Description: ________v_i_e_w__o_f__t_a_ll__c_o_r_n__f_ie_l_d_s__-_i_n_j_e_c_t_io__n__w_e__ll_i_s__n_o_t__v_is_i_b_l_e_________________________________ 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_r_l_E__. _W__e_l_le__r___________________________ Name: _______C_a__ro__l_C_h__e_n_____________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fil_ia_t_e_)_D_a_te_: 2_02_3._09_.0_1_16_:3_0:_30_-0_4_'00_' _____ Digitally signed by CARL WELLER (Affiliate) Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_23_.0_8_.31_1_6_:1_2:_00_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18