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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 3 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_0_:_4_6__a_m__ ____________________________________, ____________________________________ End Time: _1_0_:_4_9__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__-_2_____________________________________________________ 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_7__2_5_____________ Longitude (W): _____-8__6_._7_1__8_7__1_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing Other: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): __4____"__ 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_7__2_1__9_________ Longitude (W): ______-_8_6__.7__1_8_7__3_3_______ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): ____A_B____ 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_l_ls__a_r_e__l_o_c_a_t_e_d__i_n__R_e_y__n_o_l_d_s__S_t_a_t_i_o_n_,_K__Y__4_2_3__6_8____ _In__je__c_ti_o_n__l_in__e__is__d_i_s_c_o_n__n_e_c_t_e_d__. _V_a_l_v_e__i_s_c_l_o_s_e__d_o__n__th__e__c_a_s_i_n_g_._N__o__g_a_u__g_e_s_.__E_q_u_i_p_m__e__n_t_i_s__c_o_r_r_o_d_e_d__.___ _W__e__ll_w__a_s__a_b__a_n_d__o_n_e_d__f_o_r__m__a_n_y__y_e_a__r_s_. _N_o__r_e_c_o__r_d_o__f_a_c__ti_v_e__in__je__c_ti_o_n__. _N_o__r_o_a__d_s__o_r_t_r_a_i_ls_.______________ _N__o_p__r_o_d_u_c__ti_o_n__. _____________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector 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._09_.0_1 1_6_:39_:3_6_-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:_13_:5_5_-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 3 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__-_2________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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_i_g_n__o_n__t_h_e__p_r_o_p__e_r_ty_____________________________________________ 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: ________________t_a__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: _________________Time: _1__0_:_4_6__a_m___ Lat (N): ____3_7_._7_0_7__2_1_9________ Long (W) ___-_8_6__.7__1_8__7_3_3________ Description: _________________in__je_c__ti_o_n__w__e_l_l,_c__lo_s__e_-u__p____________________________________________________ Photo ID: _________________Time: _1__0_:_4_7__a_m___ Lat (N): ____3__7_._7_0_7__2_3__2______ Long (W) ___-_8_6__.7__1_8_7__4_7________ Description: _________________v_i_e_w__f_a_r_t_h_e_r__b_a_c__k_f_r_o_m___i_n_je__c_t_io__n_w__e_l_l_____________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ UIC Inspector 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_lia_t_e_)_D_a_te_: 2_02_3_.09_.0_1_16_:4_0:_25_-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_4:_27_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18