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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#: K Y S 0 Year-Month-Day: 2 0 2 3 EPA Permit # (or RA): K 99 00 - 0 7- Y I 0 4 1 0 1 8 2 0 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _______C__a_r_l _E_._W__e__ll_e_r_____________ (lead),_______C_a_r_o__l _C_h_e__n_________________ Start Time: 1__0_._2_9__a_m__ ____________________________________, ____________________________________ End Time: 1__0_.3__2_a__m__ Facility Contact Information Logsdon Valley Oil Co., Inc. Facility Name: __________________________________________________________________________________________ Street Address:_____1_0__5__B_e_d__fo__rd__C__o_u_r_t__________________________________________________________________ City: ______H__o_r_s_e__C_a_v_e_______________ County: _________H_a_r_t___________________ State:___K__Y___ Zip: __4_2__7_4__9_ Nature of Business: ______O__il_a__n_d__g_a_s__e_x__tr_a_c__ti_o_n__________________________________________________________ Facility Owner/Operator: ____L_o__g_s_d_o_n__V__a_l_le_y__O__il_C__o_._, _In__c_.__________________ Phone: ______2_7_0__-5__3_7__-4__2_8_8_____ Email: ______e_s_t_in__s_o_n_@__s_c_r_t_c_.c__o_m__________S__p_e_n__c_e_r_W___a_lt_e_r_s__s_c_w__1_0__6_@__g_m__a_i_l_.c_o__m_________________________ Facility Contact (if different): _____E_ll_e_n__S__ti_n_s_o__n_,_P__re__s_id__e_n_t____________________ Phone: ______2_7__0_-_5_3__7_-_4_2_8__8____ O/O Mailing Address: _____1_0__5__B_e__d_f_o_r_d__C_o_u__rt_____________________________________________________________ City: _____H__o_r_s_e__C_a_v_e________________ County: _________H_a__rt___________________ State:___K__Y___ Zip: __4_2__7_4_9__ Well Data from File Well Name & #: ________P_a_y_t_o_n__#_7_E__a_s_t___________________________________________________________________ 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: _____5__5_3_6_5________________ Latitude (N): ______3__7_.1__9_3_3__9_4__________ Longitude (W): ______-8__5_.7__7_6_9__5_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: ther: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): ___4___"__ Tubing Size (in):____2___"___ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _______3__7_._1_9_3_9__0__________ Longitude (W): ______-_8_5_._7_7_6__9_9_________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): ____A_B____ If not Active, Reported Date Last Active: ___5__/_2_2__/_2_0__1_9____ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _I_n_j_e_c_t_i_o_n__w_e__ll_a__n_d__t_a_n_k__b_a__t_te__ry__a_l_l_h_a__v_e__p_i_p_e_s__d_i_s_c_o_n_n__e_c_t_e_d_.________________________________________ _I_n_j_e_c_t_io__n__w_e__ll_h__a_s__o_p_e_n__t_u_b__in__g_,_n_o_t__c_l_o_s_e_d__. __________T_u__b_i_n_g__G_a__u_g_e_:_________N_/_A______________________ _L_a_r_g_e__q__u_a_n_t_i_t_ie_s__o_f__p_r_o_d_u__c_e_d__f_lu__id_s__a_r_e__f_o_u_n__d__in______P__r_o_d_u_c__ti_o_n__G__a_u_g__e_:____N_/_A______________________ _t_h_e_s_e__t_a_n__k_s_,_w__i_th__c_o__rr_o__s_io__n_o__f_p_l_u_m__b__in_g__. _____________S_u_r_f_a_c_e__G__a_u_g_e__: _______N_/_A______________________ _T_h__e_p__u_m__p__is__s_e__iz_e_d__u__p_,_r_u_s_t_e_d__o_f_f_.__________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/OpeUraICtoInr sRpeepcrteosrentative (Optional) UIC Inspector Carl E. Weller Name:_______________________________________________ Name: ________C__a_r_o_l_C__h_e_n____________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3._08_.2_9 1_7_:56_:4_1 _-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._08_.2_2_1_8:_10_:0_8_-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 9 0 0 1 0 Year-Month-Day: 2 0 2 3 - 0 7 - 1 8 EPA Permit # (or RA): K Y I 0 4 2 0 Page 2 Of 2 (Cont) ___________P_a__y_to_n__#__7_E_a_s_t_____E_P_A__P__e_rm__i_t_N__o_. _K_Y_I_0_4__2_0____S_t_a_t_e__P_e_r_m__it_N__o_._5_5__3_6_5____________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_______C_a__rl__E_._W__e__ll_e_r__________________EPA Camera ID: __________S_X_8__1_2__3_____________________ Photo ID: _____2_1__1_________Time: __1_0_._3_1__a_m___ Lat (N): ____3__7_._1_9_3_9__0________ Long (W) _____-8_5__.7__7_6_9_9_________ Description: ______________________i_n_j_e_c_t_i_o_n__w_e__ll_a__n_d__t_a_n_k_______________________________________________ Photo ID: _____2_1_2__________Time: _1__0_.3__2__a_m___ Lat (N): _____3_7_._1_9_3__8_7________ Long (W) _____-8__5_.7__7_6_9__5________ Description: _______________________2__t_a_n_k_s______________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Owner/OperUaICtoIrnRseppercetoser ntative (Optional) UIC Inspector Name:_____C__a_r_l_E_._W___e_ll_e_r_____________________________ Name: _______C_a_r_o_l__C_h_e__n_____________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3_.08_.2_9_17_:5_7:_19_-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_8_.22_1_8_:1_0:_38_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18