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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 31 01 - 07 - Y I 0 4 1 7 1 8 2 9 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _____C_a__rl__E_._W__e_l_l_e_r_______________ (lead),_______C_a__ro__l_C_h__e_n_________________ Start Time: _2_:_0_3__p__m__ ____________________________________, ____________________________________ End Time: _2__:1__5__p_m__ Facility Contact Information Facility Name:_____R_e__a_l_A__ll_o_y__R_e_c__y_c_li_n_g__, _L_L_C_____________________________________________________________ Street Address:____8_0_5__G__a_r_d_n__e_r_L_a__n_e____________________________________________________________________ City: _____M__o_r_g_a__n_t_o_w__n______________ County: ________B__u_t_l_e_r_________________ State:___K__Y___ Zip: _4__2_2_6__1__ Nature of Business: ____In_d__u_s_t_r_ia__l _-_U_s__e_d__B_e_v__e_r__a__g__e____C___a_n__R_e__c_y_c_l_in_g__O__p_e_r_a__ti_o_n________________________ Facility Owner/Operator: ____R__e_a_l_A__ll_o_y__R_e__c_y_c_l_in_g__, _L_L_C_____________________ Phone: _____2_7__0_-_5_2_6__-5__6_8__8_____ dannycarroll@realalloy.com Email: ________________________________________________________________________________________________ Facility Contact (if different): _D_a__n_n_y_C__a_r_ro__ll_, _E_n_v_i_ro__n_m__e_n_t_a_l_a_n_d__L_a_n__d_f_il_l _M_a__n_a_g_e_r Phone: _____2_7__0_-_5_1__6_-_9_1_0__6_____ O/O Mailing Address: ___8__0_5__G__a_r_d_n_e_r__L_a_n__e_______________________________________________________________ City: ______M__o_r_g_a__n_t_o_w__n_____________ County: _______B__u_t_l_e_r__________________ State:___K_Y____ Zip: __4_2__2_6__1_ Well Data from File Well Name & #: ____Im__c_o__#__1_____________________________________________________________________________ Well Type (see table): _______I_(_N_o__n_h_a__z_a_r_d_o_u__s_I_n_d__u_s_t_r_ia_l_)____________ State Permit: __________________________ Latitude (N): _____3__7_._2_0__6_4_2__7__________ Longitude (W): _____-_8_6_._7_1__7_2__1_6________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing 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): ________ Field Measurements and Observations Latitude (N): ______3__7_._2_0__6_2__9__________ Longitude (W): _____-8__6_._7_1_7__1_0__________ Elevation (ft): ____________ EPA GPS ID: __S_X_8__1_3__2 Well Status (see table): ___I_N_____ If not Active, Reported Date Last Active: ____6_/_1__4_/_2_3_______ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): _O_n__6__/_1_5__/_2_3__,_t_h_e__o_p_e__ra__t_o_r_r_e_p__o_r_te__d__to__E__P_A__t_h_i_s_w__e_l_l_ _s_h_o_w__s__p_r_e_s_s_u__re__b__u_il_d_u__p_i_n__t_h_e__a_n_n__u_l_u_s_a__n_d__n_e_e__d_s__a__re__m__e_d_i_a_t_io__n__p_la__n_._I_t_w__a_s__o_b_s_e__rv__e_d__d_u_r_i_n_g__th__e___ _i_n_s_p_e_c__ti_o_n__t_h_a_t__c_e_r_t_a_i_n_f_l_a_n_g__e_s_a__r_e_s_h__o_w__in__g_c__o_r_ro__s_io__n_a__n_d__m__a_y__n_e_e__d__to__b_e__r_e_p__la_c__e_d_.________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/OpeUraICtoIrnRspeepcretosrentative (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_li_a_te_)_D_a_te_: 2_02_3._09_.1_4 1_6_:26_:1_7_-0_4'0_0'______ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_3._09_.1_4_1_4:_35_:1_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 3 1 0 1 1 7 Year-Month-Day: 2 0 2 3 - 0 7 - 1 8 EPA Permit # (or RA): K Y I 0 4 2 9 Page 2 Of 2 (Cont) ____U_I_C__C_l_a_s_s__I_______E_P__A__ID__N__o_._K__Y_S__0_3_1__0_1__1_7__I_m__c_o__#_1_______P__e_r_m__it__N_o_.__K_Y_I_0__4_2_9________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carl E. Weller SX8132 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: _____2_3_1__________Time: __2__:0__3__p_m___ Lat (N): ____3_7__.2__0_6_2__9________ Long (W) _____-8__6_._7_1_7__1_0________ Description: ____________________in__je_c__ti_o_n__w__e_l_l _c_l_o_s_e_-_u_p__________________________________________________ Photo ID: _____2_3_2__________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ____d__e_le__te__d________________________________________________________________________________ Photo ID: _____2_3__3_________Time: ___2__:1__3__p_m__ Lat (N): ___3__7_._2_0__6_3_8_________ Long (W) _____-_8_6__.7__1_7_1__3_______ Description: ___________________d_i_s_t_a_n_t__p_h_o__to__o_f__w__e_ll__a_n_d__i_n_j_e_c_t_io__n_p__u_m__p________________________________ 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/OperUaItCorInRseppercetsoerntative (Optional) UIC Inspector Name:___________C__a_r_l_E_.__W__e_l_le_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_.09_.1_4_16_:2_8:_06_-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_9_.14_1_4_:3_5:_47_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18