Document GmDnezKp0a3wN4rGNybpkjQ6v
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 0 05
3 -03-28 N O N E
Page 1 Of 2
Start Time:12:37 pm
End Time:12:43 pm
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 & #: Well Type (see table): Latitude (N):
Albert L. Rosasco #19-4 Enhanced Oil Recovery (EOR)
30.8379534
Longitude (W):
API No. 0911320068 PA No. 303046
State Permit:
-87.07942527
OG_ 578
Elevation (ft):
Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing
PBTD: 16148' Total Depth (ft): 16250'
Other: srfc csg 10" @3721'
Inner Casing Size (in):
Tubing Size (in):
Otis WB Packer Depth (ft): 15275'
Inj. Zone: Open Hole; X Perforated; Top(ft) 15828' Bottom(ft): 15877' Max. Injection Pressure (psig): 2500 psi
Latitude (N):
30.83801
Longitude (W):
-87.07933
Elevation (ft):
EPA GPS ID: SX8123 Well Status (see table): TA If not Active, Reported Date Last Active:
2018
Nature of Injected Fluid(s) if any:
General Condition of the Well Site:
Well Data from File
Field Measurements and Observations
Notes & Comments (include discrepancies from database values):
This well is on the list for plugging and abandonment.
Tubing gauge: Production gauge: Surface gauge:
0 psi 0 psi 0 psi
Injection well passed a mechanical integrity test on 9/20/2021
Name: Signature:
See reverse for additional observations, comments and photo log
UIC Inspector
UIC Inspector
Carl E. Weller
Digitally signed by CARL WELLER
CARL WELLER (Affiliate) (Affiliate)
Date: 2023.05.11 13:14:35 -04'00'
Name: Carol Chen
Signature: CAROL CHEN Date: 2023.05.10 18:49:44 -04'00' Digitally signed by CAROL CHEN
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 0 5 Year-Month-Day: 2 0 2 3 - 0 3 - 2 8
EPA Permit # (or RA): N O N E
Page 2 Of 2
Field Measurements and Observations (Cont.)
Photo Log
Photographer: Photo ID: Description: Photo ID: Description:
Carl E. Weller
150
Time: 12:37 pm
EPA Camera ID:
Lat (N):
30.83755
sign posted
151
Time: 12:38 pm Lat (N):
30.83801
photo of injection well
SX8123
Long (W)
-87.07920
Long (W)
-87.07933
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 13:15:11 -04'00'
Name: Carol Chen
Signature: CAROL CHEN Date: 2023.05.10 18:50:18 -04'00' Digitally signed by CAROL CHEN
Version 2018-04-18