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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#: F L S 1 1 3 0 0 3 4 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C_a_r_o_l_C__h_e_n___________________ (lead), _______C_a_r_la__F_o_y_____________________ Start Time: 1__0_:_0_5__a_m__ ____________________________________ , _______________________________________ End Time:1_0__:0__9__a_m__ Facility Contact Information Facility Name:__M__a_v_e_r_i_c_k__N_a_t_u_r_a__l _R_e_s__o_u_r_c_e_s_,__L_L_C________________________________________________________ Street Address:_5__4_1__5__O_i_l _P_l_a_n_t__R_d_______________________________________________________________________ City: _____J_a_y________________________ County: ___S__a_n_t_a__R_o__s_a_________________ State:___F_L____ Zip: _3__2_5__6_5__ Nature of Business: _____o_i_l _a_n_d__g_a__s_p__ro__d_u_c_t_i_o_n___________________________________________________________ Facility Owner/Operator: _M__a_v_e__r_ic_k__N__a_t_u_r_a_l_R__e_s_o_u__rc_e__s_,_L_L_C________________ Phone: _8__5_0__-6__7_5_-_1_7__0_2_________ Email: ________________________________________________________________________________________________ Facility Contact (if different): __A_l__J_o_n_e_s_,__P_l_a_n_t__S_u_p_e__r_in_t_e_n__d_e_n__t _______________ Phone: __2_5_1__-2__2_7__-3__3_1_9_________ O/O Mailing Address: ___5_4__1_5__O__il_P__la__n_t_R__d________________________________________________________________ City: ______J_a_y_______________________ County: ____S__a_n_t_a__R_o__s_a________________ State:__F_L_____ Zip: __3_2__5_6_5__ Well Data from File Well Name & #: ________M__c_D__a_v_i_d__L_a_n__d_s__#_3_4__-1____________A_P__I _N_o__. _0_9__1_1__3_2_0__1_1__1____P__A__N_o_.__3_0_9__8_9__7_______ Well Type (see table): ___E_n__h_a_n__c_e_d__O_i_l_R__e_c_o_v_e__ry__(_E_O_R__)______________ OG_658 State Permit: __________________________ Latitude (N): ______3_0__.9__9_0_8__2_8__________ Longitude (W): _______-8__7_._1_5__8_9_1__2______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15721' Other: _____s_u_r_f_a_c_e_c_a_s_i_n_g_1_0__3_/_4_"__a_t _3_7_8_9_'__________________________________ Total Depth (ft): __1_5_8__3_0__' _ Inner Casing Size (in): 7_"__@_1__5_8_30T' ubing Size (in):3__1_/_2_"_1_5__3_00'Packer Depth (ft): 1__5_2_7__5_'_ Inj. Zone: Open Hole; X Perforated; Top(ft) 1__5_4_4__4_'_ Bottom(ft): __1__5_4_9__8_'__ 7500 N2 gas 4400psi PW Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ___N__o_G__P_S__0__0_0____________ Longitude (W): ___N__o__G_P__S__0_0_0__________ Elevation (ft): ____________ EPA GPS ID: _S__C_8__2_8_4_ Well Status (see table): ___T__A____ If not Active, Reported Date Last Active: ___9_/__0_7_/_2__1_______ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): _T_e__m__p_o_r_a_r_i_ly__A_b_a__n_d_o_n__e_d__(_T_A_)_________________________ D__A_N_G__E_R__s_i_g_n_:__H__S__M__a_y__b_e__P_r_e_s_e__n_t_.._.A__u_t_h_o_r_i_z_e_d__P_e_r_s_o_n__n_e_l_O__n_l_y_.._._H_a_z_a__rd__o_u_s__O_p__e_r_a_t_io_n__s_.._._K_e_e__p_O__u_t_._..__ _T_h_i_s_i_n_j_e_c_t_i_o_n__w_e_l_l_h_a__s_b__e_e_n__i_n_a_c_t_i_v_e_s__in_c_e__9__/_2_0__/_2_1_,_______T_u_b_i_n_g__G__a_u_g_e__: _____________5_0__0__p_s_i________ _t_e_m__p_o__ra__r_il_y_a_b__a_n_d__o_n_e_d__. _T_h_e__r_e_a_d__in_g__o_f__t_h_e__tu__b_in__g_________P_r_o_d_u__c_t_io_n__G__a_u_g__e_:_________0__p_s_i___________ _g_a__u_g_e__s_h_o__w_s__5_0__0__p_s_i_, _p_r_e_s_s__u_r_e__re__ta__in_e__d__a_f_te__r _t_h_e_________S_u_r_f_a_c_e__G__a_u_g_e__: ____________0__p_s_i___________ _w__e_ll__w_a_s__s_h__u_t_d__o_w_n__o__n_t_h__e_a__b_o_v_e__d_a__te__.__T_h_i_s_w__e_l_l _________F_lo__w__L_i_n_e__G_a__u_g_e_:__________0__p__s_i___________ passed a mechanical integrity test on 3/09/23. _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Name:______C_a__ro_l__C_h_e_n________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_50_:2_1_-0_4_'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#: F L S 1 1 3 0 0 3 4 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______M__c_D_a__v_id__L_a__n_d_s__#_3__4_-_1_________________O_G____6_5__8_________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _______C_a__rl_a__F_o_y________________ EPA Camera ID:___________S_C__8_2_8__4___________________________ Photo ID: _D__S_C__N_1__3_7_9______Time: __1_0__:0__5__a_m__ Lat (N): __N__o__G_P__S__0_0_0________ Long (W) _____N_o__G__P_S__0_0__0______ Description: __in__je_c_t_i_o_n__w__e_ll_,_i_d_e_n__ti_f_ic_a_t_i_o_n__s_i_g_n_,_D__A_N__G_E__R__s_ig__n_:__H__S__M__a_y__b_e__P__re__s_e_n_t_._.._K_e__e_p__O_u__t._..________ Photo ID: __D_S__C_N__1_3_8__0_____Time: __1_0__:0__6__a_m__ Lat (N): __N__o__G_P__S__0_0__0_______ Long (W) _____N_o__G__P_S__0_0__0______ Description: _i_n_j_e_c_t_i_o_n__tu__b_i_n_g__g_a_u_g__e_r_e__a_d_s__5_0__0__p_s_i_____________________________________________________ Photo ID: __D_S__C_N__1_3__8_1_____Time: __1_0_:_0_8__a__m__ Lat (N): __N__o__G_P__S__0_0_0________ Long (W) ____N__o__G_P__S__0_0_0_______ Description: __p_r_o_d_u_c__ti_o_n__g_a_u__g_e__r_e_a_d_s__0__p_s__i ____________________________________________________________ Photo ID: __D_S__C_N__1_3__8_2_____Time: __1_0_:_0_8__a__m__ Lat (N): __N__o__G_P__S__0_0_0________ Long (W) ____N__o_G__P_S__0__0_0_______ Description: _f_l_o_w__l_in__e_g__a_u_g_e__r_e_a__d_s__0__p_s_i_______________________________________________________________ Photo ID: __D_S__C_N__1_3_8__3_____Time: _1__0_:_0_9__a_m___ Lat (N): ___N_o__G__P_S__0_0__0_______ Long (W) ____N__o_G__P_S__0__0_0_______ Description: _s__u_r_fa__c_e__g_a_u_g__e_r_e_a__d_s__0__p_s_i________________________________________________________________ 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_.0_6._20_2_1_:50_:4_8_-0_4_'00_' ____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18