Document 9JbeeV73Xoy6Kz2gw4GKv2Xg7
Inspection ID
Facility Contact Information
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):
Carl E. Weller
_ (lead), ,
EPA Well ID#: F L S Year-Month-Day: 2 0 2
EPA Permit # (or RA):
Carol Chen
1 1 30 05 0 3 -03 -28 FL I 0020
Page 1 Of 2
Start Time: 10:07 am End Time: 10:15 am
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:
Black Creek Energy, LLC
Email:
Mike Wetzel <mikew2859@gmail.com>
Facility Contact (if different):
Michael Wetzel
O/O Mailing Address: 140 Virginia Street, Suite 302
City:
Richmond
County:
N/A
State: FL
Zip:32565-9260
Phone: 601-431-5386 Phone: 850-324-6271
State: VA Zip: 23219
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. 0911320225 PA No. 302539
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'
(10/25/20 Recertification) 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):
30.84819
Longitude (W):
-87.11890
Elevation (ft):
EPA GPS ID: SX8123 Well Status (see table): AC If not Active, Reported Date Last Active:
Nature of Injected Fluid(s) if any:
Produced fluids
General Condition of the Well Site:
Well Data from File
Field Measurements and Observations
Notes & Comments (include discrepancies from database values):
Tubing gauge: Production gauge: Surface gauge:
0 psi 0 psi 0 psi
Injection well passed a mechanical integrity test : 8/24/2022
See reverse for additional observations, comments and photo log
UIC Inspector
UIC Inspector
Name: Carl E. Weller
CARL WELLER (Affiliate) Signature:
Digitally signed by CARL WELLER (Affiliate) Date: 2023.05.11 13:33:29 -04'00'
Name:
Carol Chen
CAROL CHEN Date: 2023.05.10 19:40:23 -04'00' Digitally signed by CAROL CHEN
Signature:
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)
EPA Well ID#: F L S 1 1 3 0 0 5 0
Year-Month-Day: 2 0 2 3 - 0 3 - 2 8 EPA Permit # (or RA): F L I 0 0 2 0 Page 2 Of 2
Field Measurements and Observations (Cont.)
Photo Log
Photographer: Photo ID: Description: Photo ID: Description:
Carl E. Weller
139
Time: 10:08 am
140
Time: 10:10 am
EPA Camera ID:
Lat (N): 30.84844 sign posted
Lat (N): 30.84819 photo of injection well
SX8123 Long (W) -87.11872
Long (W) -87.11890
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: Signature:
Carl E. Weller
Digitally signed by CARL WELLER
CARL WELLER (Affiliate) (Affiliate)
Date: 2023.05.11 13:33:56 -04'00'
Name: Carol Chen
CAROL CHEN Date: 2023.05.10 19:40:53 -04'00' Digitally signed by CAROL CHEN
Signature:
Version 2018-04-18