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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 Year-Month-Day: 2 0 2 4 - EPA Permit # (or RA): F L 3 007 9 0 5- 0 1 I 0 0 51 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C_a_r_o_l_C_h_e__n___________________ (lead), ______C_a_r_l_a_F__o_y_____________________ Start Time: _1_0_:_4_4__a__m__ ____________________________________ , _______________________________________ End Time:1__0_:_5_3__a_m__ Facility Contact Information Well Data from File 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________(_B_r_e_i_tb__u_r_n__O_p_e__ra__t_in_g__, _L_P_)________________________ 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 Name & #: ______D_o__u_g_l_a_s__P_o_l_k__E_t_a_l_#__4_1_-_1____________________________A_P__I _N_o__. _0_9__-1__1_3__-2__0_1_5__4_-_0_1______ Well Type (see table): _____________N_I________________________________ State Permit: ____O__G___8__8_2_______________ Latitude (N): ____3__0_._9_5_1__8_9__6_5__________ Longitude (W): ____-_8_7__.1__4_1_9__8_2__9_6______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15762' Other: _c_o__n_d_u_c__to__r_c_s_g__1_6__"_@__1_0__1_'_, _s_u_r_f_a_c_e__c_s_g__9____"_@__3_8__0_6__' _____________ 15839' 7" 15836'Tubing Size (in): has a 3 1/2" production tubing Total Depth (ft): __________ Inner Casing Size (in): ________ Packer Depth (ft): ________ Inj. Zone: Open Hole; X Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ 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): ____N__I___ 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): __N_o__t _I_n_je__c_ti_n_g__(_N_I_)_s_t_a_t_u__s_; _is__a__s_h_u__t-_i_n__p_r_o_d_u_c__e_r_. ______ _T_h__is__w_e__ll_i_s__a__p_r_o_d_u_c__e_r_, _n_o_t__a_n__in__je__c_ti_o_n__w__e_l_l,_a__lt_h_o_u__g_h__h_a_s__a__d_r_a_f_t_p__e_r_m__it__w_i_t_h_E__P_A_.__________________ _____________________________________________________________________________________________________ ___________________________________________________________T_u_b_i_n_g__G_a_u_g_e__: ____0__p_s_i_____________________ _______________________________________________________P__ro_d__u_c_t_io_n__G_a__u_g_e_:____0__p_s__i ____________________ Surface Gauge: not visible _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Field Measurements and Observations 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:_55_:4_8_-0_4_'00_'___ 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 EPA Well ID#: F L S 1 1 3 0 0 7 9 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 5 1 Phone: (404)562-9424 Page 2 Of 2 (Cont) ____D_o__u_g_l_a_s__P_o_l_k__E_t_a_l_#__4_1_-_1_____O__G____8_8_2_________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _______C__a_r_la__F_o_y________________ EPA Camera ID:__________S__C_8_2__8_4____________________________ Photo ID: __D_S__C_N__1_3_9__7_____Time: _1__0_:_5_1__a_m___ Lat (N): ___N__o_G__P_S__0__0_0_______ Long (W) _____N_o__G__P_S__0_0__0______ Description: __W__e_ll__id_e__n_t_if_i_c_a_t_io__n_s__ig_n__a_t__t_h_e__e_n_t_r_a_n_c__e_o__f_t_h_e__p_r_o_p_e__r_ty____________________________________ Photo ID: __D_S__C_N__1_3_9__8_____Time: _1_0_:_5_2__a_m____ Lat (N): ___N_o__G__P_S__0_0__0_______ Long (W) ____N__o__G_P__S__0_0_0_______ Description: _P__ro__d_u_c_t_i_o_n__w_e__ll_,_id__e_n_t_i_fi_c_a_t_i_o_n__s_ig__n_,_D__A_N__G_E_R___s_ig_n__: _H__S__M__a__y_b__e_P__r_e_s_e_n_t_._..__________________ Photo ID: __D_S__C_N__1_3_9__9_____Time: _1_0_:_5_3__a_m____ Lat (N): ___N_o__G__P_S__0_0__0_______ Long (W) _____N_o__G__P_S__0_0__0______ Description: _p__ro__d_u_c_t_i_o_n__g_a_u__g_e__re__a_d_s__0__p_s_i__a_n_d__s_u_r_f_a_c_e__g_a__u_g_e__d_o__e_s__n_o_t_s__h_o_w__a__v_i_s_i_b_le__r_e_a__d_in__g_________ Photo ID: __D_S__C_N__1_4__0_0_____Time: _1__0_:_5_3__a_m___ Lat (N): ___N_o__G__P_S__0_0__0_______ Long (W) _____N_o__G__P_S__0_0__0______ Description: __t_u_b_i_n_g__g_a_u__g_e__re__a_d_s__0__p_s_i_________________________________________________________________ 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_:5_6:_13_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18