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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 9 Year-Month-Day: 2 0 2 4 - EPA Permit # (or RA): K Y 9 0 0 2 I 0 0 04 - 21 38 9 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _____C__a_r_o_l_C__h_e_n__________________ (lead),______B_r_i_a_n_n__a__L_a_P_a__p_a_____________ Start Time: _9_:_2_4__a_m___ ____________________________________, ____________________________________ End Time: _9_:_3_2__a_m___ Facility Contact Information Logsdon Valley Oil Co., Inc. Facility Name: __________________________________________________________________________________________ Street Address:______1__0_5__B__e_d_f_o_r_d__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_i_l_a_n__d__g_a_s__e_x_t_r_a_c_t_io__n_________________________________________________________ Facility Owner/Operator: ________L__o_g_s_d__o_n__V_a_l_le__y_O__il_C__o_._,_I_n_c_.______________ Phone: ____2__7_0_-_5_3__7_-_4_2__8_8______ Email: _______e_s__ti_n_s_o__n_@__s_c_r_tc__.c_o__m______________________________________________________________________ Facility Contact (if different): _____E_l_le_n__S__ti_n_s_o__n_,_P_r_e__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__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_ Well Data from File Well Name & #: _______G__u_i_n_n__#_U__A_-_3_____________________________________________________________________ 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: _____7_7__8_0__4_______________ Latitude (N): _____3_7__.1__7_7_5__2_8___________ Longitude (W): _______-8__5_._7_8_9__1_7________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing PBTD: Other: ___s_u_r_f_a_c_e__c_a_s_i_n_g__1__3_0__f_e_e_t__d_e_e_p__, _8___"__h_o_l_e________________________ Total Depth (ft): 627' __________ Inner Casing Size (in):4___"__6_2__5' Tubing Size 4" (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__.1__7_5__2_7_8____________ Longitude (W): _____-_8_5__.7__8_9__1_6_7________ Elevation (ft): ____________ EPA GPS ID: _S_7__5_3_2__2_ Well Status (see table): ___I_N_____ If not Active, Reported Date Last Active: ____3_/_1__7_/_1_6_______ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _I_n_p__re__p_a_r_a_t_i_o_n__fo__r_t_h_e__u_p_c__o_m__in__g_p__lu_g__g_in__g_a__n_d__a_b_a__n_d_o_n__m__e_n_t__o_f_G__u_in__n__#_U_A__-3__, _a__m__o_b_i_le__w__o_r_k_o_v_e_r______ _r_ig__w__a_s__p_l_a_c_e_d__o_n__s_it_e__w__it_h__a__c_a_b_l_e__t_o_o_l_t_o__in__s_e_r_t_a__s_u_c__k_e_r_r_o_d__i_n_t_o__t_h_e__in__je_c__ti_o_n__w__e_ll_'s_________________ _p__ro__d_u_c_t_i_o_n__c_a_s_i_n_g__f_o_r_c_e__m__e_n_t_a_t_i_o_n_._________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/Operator Representative (Optional) UIC Inspector Name:_______C_a__r_o_l__C_h__e_n_____________________________ Name: ______________________________________________ CAROL CHEN Digitally signed by CAROL CHEN Date: 2024.03.27 18:51:35 -04'00' Signature: ___________________________________________ Signature: ___________________________________________ 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 9 9 0 0 0 4 Year-Month-Day: 2 0 2 4 - 0 2 - 2 1 EPA Permit # (or RA): K Y I 0 3 8 9 Page 2 Of 2 (Cont) __U_I_C__C_l_a_s_s__I_I__G_u__in__n__#_U_A__-3______________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photographer:_____B_r_ia__n_n_a__L_a__P_a_p__a__________________EPA Camera ID: ________S__7_5_3__3_2_______________________ Photo ID: ____R_I_M__G_0_0__9_____ Time: __9_:_2_7__a_m____ Lat (N): _____3_7_._1_7_5__3_4_4_______ Long (W) ____-_8_5_._7_8_9__1_2_8_______ 78 tank battery and truck-mounted mobile workover rig at injection well Description: ____________________________________________________________________________________________ Photo ID: ____R_I_M__G_0_1__0_____ Time: __9_:_2_7__a_m____ Lat (N): 37.175278 _____________________ Long (W) ____-_8_5__.7_8__9_1_6__7______ Description: __i_n_je__c_ti_o_n__w__e_l_l,_s_u__c_k_e_r__r_o_d__in__c_a__s_in__g________________________________________________________ Photo ID: ____R_I_M__G_0_1__1_____ Time: __9_:_3_4__a_m____ Lat (N): ____3_7_._1_7_5__3_5_5________ Long (W) _____-8_5__.7__8_9_1_5__3______ workover rig over injection well Description: ____________________________________________________________________________________________ Photo ID: ____R__IM__G_0__1_2_____ Time: 9:34 am ____________ Lat (N): ____3_7_._1_7_5__3_4_2________ Long (W) _____-8__5_._7_8_9__1_5_8______ Description: __c_l_o_s_e_r__v_ie__w__o_f_w__o_r_k_o__v_e_r_r_i_g_a__n_d__in__je__c_ti_o_n__w__e_l_l _____________________________________________ Photo ID: _________________ Time: ____________ Lat (N): _____________________ Long (W) _____________________ Description: __________________________________________________________________________________________ Photo Log Owner/Operator Representative (Optional) Carol Chen Name:_______________________________________________ CAROL CHEN Digitally signed by CAROL CHEN Date: 2024.03.27 18:52:07 -04'00' Signature: ___________________________________________ UIC Inspector Name: ______________________________________________ Signature: ___________________________________________ Version 2018-04-18