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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 Phone: (404)562-9424 EPA Well ID#: K Y S 0 9 9 0 0 0 5 Year-Month-Day: 2 0 2 3 - 0 7 - 1 8 EPA Permit # (or RA): K Y I 5 9 0 Page 1 Of 2 Inspector(s): _______C__a_r_l _E_._W__e__ll_e_r_____________ (lead),_______C_a_r_o__l _C_h_e__n_________________ Start Time: 1__0_:_5_9__a_m__ ____________________________________, ____________________________________ End Time: 1__1_:_0_2__a_m__ Facility Contact Information Logsdon Valley Oil Co., Inc. Facility Name: __________________________________________________________________________________________ Street Address:_____1_0__5__B_e_d__fo__rd__C__o_u_r_t__________________________________________________________________ City: ______H__o_r_s_e__C_a_v_e_______________ County: ________H__a_r_t___________________ State:___K__Y___ Zip: __4_2__7_4__9_ Nature of Business: ______O__il_a__n_d__g_a_s__e_x__tr_a_c__ti_o_n__________________________________________________________ Facility Owner/Operator: ____L_o__g_s_d_o_n__V__a_l_le_y__O__il_C__o_._, _In__c_.__________________ Phone: ______2_7_0__-5__3_7__-4__2_8_8_____ Email: ______e_s_t_in__s_o_n_@__s_c_r_t_c_.c__o_m__________S__p_e_n__c_e_r_W___a_lt_e_r_s__s_c_w__1_0__6_@__g_m__a_i_l_.c_o__m_________________________ Facility Contact (if different): _____E_ll_e_n__S__ti_n_s_o__n_,_P__re__s_id__e_n_t____________________ Phone: ______2_7__0_-_5_3__7_-_4_2_8__8____ O/O Mailing Address: _____1_0__5__B_e__d_f_o_r_d__C_o_u__rt_____________________________________________________________ City: _____H__o_r_s_e__C_a_v_e________________ County: ________H__a_r_t___________________ State:___K__Y___ Zip: __4_2__7_4_9__ Well Data from File Carter & Chaney #VA-2 Well Name & #: ________________________________________________________________________________________ Well Type (see table): ______E_n_h__a_n_c_e__d__O_i_l _R_e__c_o_v_e_r_y__(_E_O_R__)___________ State Permit: _______3__6_4__7__1____________ Latitude (N): ______3_7_._1_8__3_4__1___________ Longitude (W): ______-8__5_._7_8_5__2_2_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: Other: __________________________________________________________________ Total Depth (ft): ___6__2_5_'___ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: pen Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ______3_7__.1__8_3_3__9___________ Longitude (W): _______-8__5_._7_8_5__2_6________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): ___P_A_____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _P_l_u_g_g__e_d__&__a_b__a_n_d__o_n_e_d__o__n_1__/_2_4__/_2_0__2_3_.______________________________________________________________ _C__a_s_i_n_g__is__v_i_s_ib__le__o_n__s_it_e__. _____________________________T_u__b_i_n_g__G_a__u_g_e_:________N__/_A______________________ ______________________________________________________P__r_o_d_u_c__ti_o_n__G__a_u_g__e_: ___N__/_A______________________ _______________________________________________________S_u_r_f_a_c_e__G__a_u_g_e__: ______N__/_A______________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/OpeUraICtoInr sRpeepcrteosrentative (Optional) UIC Inspector Carl E. Weller Name:_______________________________________________ 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._08_.2_9 1_8_:02_:0_3_-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._08_.2_2_1_7:_01_:5_4_-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 EPA Well ID#: K Y S 0 9 Year-Month-Day: 2 0 2 3 - EPA Permit # (or RA): K Y 9 00 05 07 - 18 I 5 90 Phone: (404)562-9424 Page 2 Of 2 (Cont) _____C_a_r_t_e_r__&__C_h__a_n_e__y_#__V_A_-_2______E_P__A__P_e__rm___it__N_o_.__K_Y_I_0_5__9_0______S__t_a_t_e__P_e_r_m__i_t_N__o_._3__6_4_7__1_________ __________P__lu__g_g_e_d__&___a_b_a__n_d_o_n__e_d__o_n__1__/_2_4__/_2_0_2__3_._C__a_s_i_n_g__i_s_v_i_s_i_b_l_e_o__n_s_i_te__. ___________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_______C_a__rl__E_._W__e__ll_e_r__________________EPA Camera ID: __________S_X_8__1_2__3_____________________ Photo ID: _____2_1__5_________Time: _1__1_:_0_1__a_m___ Lat (N): ____3_7__.1__8_3__3_9________ Long (W) _____-8__5_._7_8__5_2_6________ Description: _____________________p__lu_g__g_e_d__c_a_s__in_g__c_l_o_s_e__-u__p______________________________________________ Photo ID: _____2_1_6__________Time: _1__1_:_0_1__a_m___ Lat (N): _____3_7_._1_8__3_4__3_______ Long (W) _____-_8_5_._7_8__5_2__7_______ tank battery and plugged casing 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: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Owner/OperUaICtoIrnRseppercetoser ntative (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_lia_t_e_)_D_a_te_: 2_02_3_.08_.2_9_18_:0_2:_30_-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_8_.22_1_7_:0_2:_22_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18