Document 8ROQzJjMv6RBqbpwX2oN3zdNe
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
Inspector(s):
Carol Chen
_ (lead), ,
EPA Well ID#: F L S Year-Month-Day: 2 0 2
EPA Permit # (or RA):
Carla Foy
1 1 30 4 -05 F L I 0
Page 1
Start Time:
End Time:
05 0 - 01 0 2 0 Of 2
1:14 pm
1:17 pm
Facility Contact Information
Facility Name: Street Address: City:
Black Creek Energy, LLC
4940 Blackjack Plant Rd.
Jay
County:
Santa Rosa
Nature of Business:
Oil and gas production
Facility Owner/Operator: Email:
Harris D. Butler, III h arris.butler@butlerroyals.com
Facility Contact (if different):
O/O Mailing Address: 140 Virginia Street, Suite 302
City:
Richmond
County:
N/A
State: FL
Zip:32565-9260
Phone: (804)-334-0527
Phone:
State: VA Zip: 23219
Well Data from File
Well Name & #:
Black Jack Creek (BJC) SWDS #1-3
Well Type (see table): Produced Water Disposal (PWD)
Latitude (N): 30.84805556
Longitude (W):
API No. 0911320136 PA No. 303039
State Permit:
-87.11888889
OG_1107
Elevation (ft):
Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing
PBTD: 6930'
Other: srfc csg 9" @ 2327'
Packer: AS1-X
Total Depth (ft): 7003' Inner Casing Size (in):
Tubing Size (in):
Packer Depth (ft): 6157'
Inj. Zone: Open Hole; X Perforated; Top(ft) 6311' Bottom(ft): 6900' Max. Injection Pressure (psig): 1800 psi
Latitude (N): No GPS 000
Longitude (W): No GPS 000
Elevation (ft):
EPA GPS ID: SX8123 Well Status (see table): SI
If not Active, Reported Date Last Active: 11/20/23
Nature of Injected Fluid(s) if any:
General Condition of the Well Site:
Field Measurements and Observations
Notes & Comments (include discrepancies from database values):
This well is inactive, shut-in.
Tubing gauge: Production gauge: Surface gauge:
0 psi 0 psi can't read gauge
Name:
See reverse for additional observations, comments and photo log
U IC Inspector
UIC Inspector
Carol Chen
Name:
Signature: CAROL CHEN
Digitally signed by CAROL CHEN Date: 2024.06.24 11:04:08 -04'00'
Signature:
UIC Inspector:
UIC Inspector:
Version 2018-04-18
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
(Cont)
Black Jack Creek (BJC) SWDS #1-3
EPA Well ID#: F L S 1 1 3 0 0 5 0 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1
EPA Permit # (or RA): F L I 0 0 2 0 Page 2 Of 2
Field Measurements and Observations (Cont.)
Photo Log
Photographer:
Carla Foy
EPA Camera ID:
Photo ID: DSCN1427 Time: 1:15 pm Lat (N): No GPS 000
Description: well identification sign posted at the property entrance
Photo ID: DSCN1428 Time: 1:16 pm Lat (N): No GPS 000
Description: injection well
photo of injection well
Photo ID: DSCN1429 Time: 1:16 pm Lat (N): No GPS 000
Description: tubing gauge reads 0 psi
Photo ID: DSCN1430 Time: 1:17 pm Lat (N): No GPS 000
Description: production gauge reads 0 psi, surface gauge is defective
Photo ID:
Time:
Lat (N):
Description:
Photo ID:
Time:
Lat (N):
Description:
U IC Inspector)
Name: Carol Chen
Name:
Signature: CAROL CHEN
Digitally signed by CAROL CHEN Date: 2024.06.24 11:03:38 -04'00'
Signature:
SC8284
Long (W)
No GPS 000
Long (W) No GPS 000
Long (W) No GPS 000
Long (W) No GPS 000
Long (W)
Long (W)
UIC Inspector
Version 2018-04-18
UIC Inspector:
UIC Inspector: