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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 1 0 1 2 4 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 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_1_:_1_0__a_m__ ____________________________________, ____________________________________ End Time: _1_1_:_1_1__a_m__ Facility Contact Information Facility Name:_____W___e_s_t_K__e_n_t_u_c__k_y__E_n_e_r_g_y__R__e_s_o_u__rc_e__s_,_L_L_C_______________________________________________ Street Address:______3_8__3_0__V_i_n_c_e__n_t_S__ta__ti_o_n__D__r_iv_e_________________________________________________________ City: ____O_w__e_n_s__b_o_r_o_________________ County: _______H__a_n__c_o_c_k________________ State:___K__Y___ Zip: __4_2__3_0__3_ Nature of Business: _______O_i_l_a_n__d_g__a_s__e_x_t_r_a_c_t_io__n_________________________________________________________ Facility Owner/Operator: ____W___e_s_t_K__e_n_t_u_c__k_y__E_n_e_r_g_y__R__e_s_o_u__rc_e__s_,_L_L_C_______ Phone: ____2_7__0_-_9_2_6__-1__6_8__9______ Email: ________________________M__r_. _G_l_e_n_n__R__ig__g_s_,_p__h_o_n_e__: _2_7__0_-_3_1__6_-_7_4_8__7_________________________________ Facility Contact (if different): ___M__r_. _V_i_n_c_e_n__t_B__. _H_a__y_d_e_n_,__J_r._,_M__a_n__a_g_e_r__________ Phone: ____2_7_0__-6__8_3__-3__0_5_7_______ O/O Mailing Address: ___3__8_3__0__V_in__c_e_n_t__S_t_a_t_i_o_n__D_r_i_v_e______________________________________________________ City: ____O__w_e_n__s_b_o_r_o_________________ County: _______H_a_n__c_o_c_k_________________ State:___K__Y___ Zip: __4_2__3_0__3_ Well Data from File Well Name & #: ______M__a_r_y_M__a__d_d_e_n__-R__ic__h_a_r_d_s___#_W__-_3_____________________________________________________ Well Type (see table): ____E_n__h_a_n_c__e_d__O_i_l_R__e_c_o_v_e__ry__(_E_O__R_)_____________ State Permit: __________________________ Latitude (N): _______3_7_._7_0__6_4__8_1_________ Longitude (W): _______-_8_6_._7_1__8_6__5_4______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing Other: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (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__.7__0_6_8__8___________ Longitude (W): _____-_8_6__.7__0_6__8_8_________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): _________ If not Active, Reported Date Last Active: __U_n_k__n_o_w__n________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): __W___e_ll_s__a_r_e__lo__c_a_t_e_d__i_n_R__e_y_n__o_ld__s_S__t_a_t_io__n_,_K__Y_4__2_3__6_8___ _T_h_e__t_a_n_k__b__a_t_te__ry__i_s_d__is_c_o__n_n_e_c__te__d_f_r_o_m___i_n_je__c_t_io_n__l_in__e_s_._N__o__p_r_o_d_u__c_ti_o_n__. _N_o__r_o_a_d__s_o__r_t_r_a_il_s_._T_h__is__w__e_ll____ _i_s_n_o__t_v_i_s_ib__le__d_u__e__to__t_a_l_l_c_o_r_n_f_i_e_l_d_s_,_i_m__p_e_d__in_g__t_h_e__p_a__t_h_w_a__y_._S_t_a_n__d_i_n_g__a_t_t_h_e__e_d__g_e__o_f_t_h__e_c_o__r_n_f_ie_l_d_,____ _p_h_o__to__s_w__e_r_e__t_a_k_e__n_._W__e__h_a_v__e_n__o__re__c_o_r_d__in__t_h_e__p_a__s_t_o_f__a_c_t_iv_e__i_n_j_e_c_t_io__n__a_t_t_h_i_s__w_e_l_l_s_i_t_e_._______________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector 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_li_a_te_)_D_a_te_: 2_02_3._09_.0_1 1_6_:41_:4_7_-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_.3_1_1_6:_15_:1_1_-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 1 0 1 2 4 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 Phone: (404)562-9424 Page 2 Of 2 (Cont) ___M__a__ry__M__a_d_d__e_n_-_R_i_c_h_a__r_d_s___#_W__-_3_______________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:________C__a_r_l _E_._W__e__ll_e_r_________________EPA Camera ID: _______S_X__8_1__2_3________________________ Photo ID: ____2__3_4__________Time: __1_0_:_3_5__a__m__ Lat (N): ____3_7__.7__0_7__8_1_2_______ Long (W) ____-_8_6__.7__1_9_4__3_9_______ Description: ___________________o__p_e_r_a_t_o_r_'_s_s__ig_n__o__n_t_h__e_p__ro__p_e_r_t_y_________________________________________ Photo ID: _____2_3_5__________Time: __1_0_:_3_5__a__m__ Lat (N): ____3__7_._7_0__7_8_0__9______ Long (W) ____-_8_6__.7__1_9__4_4__8______ Description: ____________________ta__n_k__b_a_t_t_e_r_y__a_n_d__o_p__e_r_a_t_o_r_'s__s_i_g_n________________________________________ Photo ID: _____2_4_0__________Time: _1__1_:_1_0__a_m___ Lat (N): ____3__7_._7_0__4_4__7_1______ Long (W) ____-_8_6__.7__1_5_0__5_9_______ Description: ___________________v_i_e_w__o_f__t_a_l_l _c_o_r_n_f_i_e_ld__s_,_w__h_e_r_e__t_h_e__w__e_ll__is__n_o_t__v_i_s_ib_l_e______________________ Photo ID: _____2_4__1_________Time: __1_1__:1__1__a_m__ Lat (N): _____3_7__.7__0_4_4__8_6______ Long (W) _____-8__6_._7_1__5_0_6__7______ Description: ___________________a_n__o_t_h_e_r__p_h_o_t_o__o_f__t_a_ll__c_o_r_n_f_i_e_ld__s_,_w__h_e_r_e__t_h_e__w_e__ll__is__n_o_t__v_is__ib_l_e____________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ UIC Inspector UIC Inspector Name:______C_a__rl__E_._W__e__ll_e_r____________________________ Carol Chen Name: ______________________________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3_.09_.0_1_16_:4_2:_18_-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_.31_1_6_:1_5:_40_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18