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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program EPA Well ID#: K Y S 1 5 3 0 1 3 3 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 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),_____L_o__n_n__ie__D__o__r_n________________ Start Time: _9_:_5_6__a__m__ ____________________________________, ____________________________________ End Time: 9__:_5_8__a__m__ Facility Contact Information Facility Name:___S__l_o_n__e__E_n__e_r_g__y_,_L__L_C___________________________________________________________________ Street Address:____8_9_6__6__K__Y__R__T__4__0__W__e__s_t_,_P__._O__._B__o_x__2__2_0______________________________________________ City: _____O__il__S_p__r_in__g_s_______________ County: _____M__a__g_o_f_f_in__________________ State:_K_Y______ Zip: _4_1__2_3__8__ Nature of Business: _________o_i_l _p_r_o__d_u__c_t_io__n______________________________________________________________ Facility Owner/Operator: ___M__r_.__S_.__C__h_r_is__S__l_o_n__e_,_P__E______________________ Phone: _6__0_6__.2__9_7__.5__3_3__0__w__o_r_k__ Email: ______c_h_r_i_s_s_lo__n_e_@___s_l_o_n_e__e_n_e__rg__y_.c__o_m_____________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: _6_0__6_._2_2__5_._2_2__0_6__c__e_l_l ___ O/O Mailing Address: ____________________________________________________________________________________ City: _______________________________ County: _______________________________ State:________ Zip: _________ Well Data from File Well Name & #: ______J__._H___._A__R__N__E__T__T___#__W__-_1__1_______________________________________________________ Well Type (see table):C_l_a_s__s__II_-_R__,_E__n__h_a_n__c_e__d__O__il__R_e__c_o__v_e_r_y__(_E__O__R_) State Permit: __________________________ Latitude (N): ______3_7__.7__0_4__9_2_7__________ Longitude (W): ___-8__3_._0_0__9_8__1_6__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing Other: _4____"__p_r_o__d_u_c__ti_o_n___c_a_s__in__g________________________________________ Total Depth (ft): __________ Inner Casing Size (in): _2_____"__ Tubing Size (in):____1_"_____ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ______3__7_._7_0__4_6_3__5_________ Longitude (W): ____-_8__3_._0_1__1_3_3__5________ 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_t_e__rs__(_P__W__)_______________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ T__h_e___in__je__c_t_io__n__li_n_e__i_s__c_o__n_n__e_c_t_e__d_,_f_e__e_l_s__ic_y__c__o_l_d_.__P_r_o__d_u_c__e_d__w__a__te__r_s__a_r_e__b__e_i_n_g__i_n_j_e_c_t_e__d__to_______ e__n_h_a_n__c_e__o_i_l_r_e_c_o__v_e_r_y_._N__o__g_a__u_g_e__s__w_e__re__a__tt_a_c__h_e_d__t_o__m__o_n__it_o_r__th_e__i_n_j_e_c_t_i_o_n__a_n__d__a_n_n_u__lu__s__p_r_e_s_s_u__re__s_._ T__h_is__i_n_j_e_c_t_io__n__w_e__ll_w__a_s__b__a_d_l_y__c_o_v_e__re__d__b_y__o_v_e__r_g_r_o_w__th__a__n_d__u_n__d_e_r_b_r_u__s_h_e_s__a__n_d__w__a_s__d_i_ff_ic__u_l_t _to__r_e__a_c_h_. T__h_e___w_e__ll_c_a__p__s_h__o_w__s__c_o__rr_o__s_i_o_n_.____________________________________________________________________ _____________________________________________________________________________________________________ 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._12_.1_1_1_3:_47_:4_9_-0_5_'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#: K Y S 1 5 3 0 1 3 3 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ __________J_._H__._A__R__N_E__T_T___#_W__-_1_1___________C__l_a_s_s__I_I-_R__,_E__n_h_a__n_c_e__d__O_i_l_R__e_c_o__v_e_r_y__(_E_O__R__)_______________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:______C_a__r_o_l_C__h__e_n_____________________EPA Camera ID: ____S__7_5__3_3_2___________________________ Photo ID: _R__IM__G__0_1__8_5______Time: _9_:_5_6__a__m____ Lat (N): ____3__7_._7_0_4__6_3_5_______ Long (W) ____-_8_3_._0_1__1_3_3_5________ Description: _C__l_o_s_e_-_u__p__v_ie__w__o_f__in_j_e_c_t_i_o_n__w__e_l_l __________________________________________________________ Photo ID: _R__IM___G__0_1_8__6_____Time: _9_:_5_8___a_m____ Lat (N): ____3_7__.7__0_4__5_5_3_______ Long (W) ____-_8_3__.0__1_1__1_6_8_______ Description: _I_n__je__c_t_io__n__w__e_l_l,__o_p__p_o_s__it_e__s_i_d_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: ___________________________________________________________________________________________ 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_.1_2_.11_1_3_:4_8:_14_-0_5_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18