Document LK2w1QnOOk15poo9gpa55wJr7

DownloadSearchable PDFRandom document
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 4 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 4 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ________C_a_r_o_l_C_h_e__n_________________ (lead), ______C__a_rl_a__F_o_y_____________________ Start Time: _2_:_5_8__p__m__ ____________________________________ , _______________________________________ End Time: _3_:_0_0__p_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 Field Measurements and Observations Well Name & #: __S__t._R__e_g_i_s__S_W__D__S__#_9_-_5______________________A_P__I _N_o__. _0_9__-1__1_3_-_2_0__1_9__9______P_A__N__o_._3__1_1_6__4_1__ Well Type (see table): Produced Water Disposal (PWD) ______________ State Permit: OG_1078 Latitude (N): _____3_0_._9_5_7__1_4_1_7__1______ Longitude (W): ____-_8_7_._1_8_4__6_3_2_8_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 6743' surface casing 10 3/4" at 2324' Other: __________________________________________________________________ Total Depth (ft): __6__7_8_6__' __ 7" 6786' Inner Casing Size (in): ________ Tubing Size (in):_4_1_/_2_"_a_t__6_240P'acker Depth (ft): 6__3_2__0_'__ Inj. Zone: Open Hole; X Perforated; Top(ft) __6_3_7__5_'_ Bottom(ft): ___6__6_1__2_'__ Max. Injection Pressure (psig):1_8_0__0__p_s_i Latitude (N): ______3_0_._9_5__7_0__9___________ Longitude (W): ____-_8_7__.1__8_4__2_9__________ Elevation (ft): ____________ EPA GPS ID: S__7_5_3__3_2__ Well Status (see table): ____T_A____ If not Active, Reported Date Last Active: ____2_/_2__3__/_1__6_____ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ D__A_N__G_E_R__s__ig_n__i_s_p__o_s_t_e_d_:_H___S__M__a_y__B_e__P_r_e_s_e__n_t_...__H_a_z_a__rd__o_u_s__O_p__e_r_a_t_io_n__s_.._._A_u_t_h_o_r_i_z_e_d__P_e_r_s_o__n_n_e_l__O_n_l_y_.._.___ _A_n__i_d_e_n_t_i_f_ic_a_t_i_o_n__s_ig__n_w__a_s__p_o__s_te__d_a__t_t_h_e__in__je_c_t_i_o_n__w_e__ll_._______T_u_b__in_g__g_a_u_g_e__: _______2_0__0__p_s_i_____________ _N__e_a_r_t_h__e_t_u_b__in__g_g__a_u_g_e__w__a_s__a__m__e_t_a_l_s_i_g_n__s_h_o_w__i_n_g__th__e________P_r_o_d_u__c_ti_o_n__g_a_u_g_e_:____0__p_s_i_?_______________ _m__a_x_i_m__u_m___in__je_c__ti_o_n__p_r_e_s__s_u_r_e__is__1_8__0_0__p_s__i.___________________S_u_r_f_a_c_e__g_a_u_g_e_:_______0__p_s_i________________ _P_r_e_s_s_u__r_e_f_r_o_m___th__e__fo__rm__a__ti_o_n__w__a_s__re__ta__in__e_d__w_i_t_h_in__t_h_e_________F_l_o_w__li_n_e__g_a_u_g_e__: _________________________ _t_u_b_i_n_g__a_n_d__c_a__s_in__g_o__f_t_h_e__in__je_c__ti_o_n__w_e__ll_._T_h_e__re__i_s__s_o_m__e__c_o_r_r_o_s_io__n__o_f_m__e_t_a_l_r_a__il_in_g__s_, _p_i_p_i_n_g__a_n_d__v_a__lv_e_s__. _ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Carol Chen Name:_______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_34_:5_5_-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 4 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 4 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ___________S_t_._R__e_g_i_s_S__W__D_S__#__9_-_5___________O__G____1_0_7__8_____________A_P_I__N_o_.__0_9__-1__1_3_-_2_0__1_9__9_______________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: ___R_I_M__G_0__1_5__4____Time: __2_:_5_7__p__m___ Lat (N): ___3_0__.9__5_7__0_1_5________ Long (W) _____-8__7_._1_8_4__2_7__8______ injection well, well identification sign and DANGER sign posted: HS May Be Present...Hazardous... Description: ___________________________________________________________________________________________ Photo ID: ___R__IM__G__0_1_5__5____Time: __2_:_5_8__p__m___ Lat (N): ___3_0__.9__5_7__0_9_________ Long (W) ____-_8_7__.1__8_4__2_9________ Description: _s_u_rf_a_c_e__g_a_u_g__e_a_n__d_p__ro_d__u_c_t_io_n__g_a_u_ge _______________________________________________________ Photo ID: ___R__IM__G__0_1__5_6____Time: __2_:_5_8__p__m___ Lat (N): ___3_0__._9_5_7__0_5_________ Long (W) _____-8__7_._1_8_4__2_8________ Description: _t_u_b_i_n_g_g_a__u_g_e_s_h__o_w_s__2_0_0__p_s_i_f_r_o_m__t_h_e_u__n_d_e_r_g_r_o_u_n_d__p_r_e_s_s_u_r_e_o__f _th__e_f_o_r_m_a__ti_o_n_____________________ 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:_______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_:3_5:_20_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18