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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 9 0 0 1 0 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 EPA Permit # (or RA): K Y I 0 4 2 0 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ____C__a_r_o_l__C_h__e_n__________________ (lead),___L__o_n__n__ie___D__o_r_n_________________ Start Time: _7_:_5_6__a__m__ ____________________________________, ____________________________________ End Time: _7_:_5_9__a__m__ Facility Contact Information Facility Name:______L__o_g_s_d__o_n__V__a_l_le_y__O__i_l _C__o_.,__In__c_._______________________________________________________ Street Address:________1__0_5__B__e_d_f_o_r_d__C__o_u_r_t______________________________________________________________ City: ___H__o__rs__e__C__a_v__e_______________ County: ______H__a_r_t_____________________ State:__K__Y____ Zip: _4_2__7_4__9__ Nature of Business: ___________o__il_p__r_o_d__u_c_t_i_o_n____________________________________________________________ Facility Owner/Operator: _____M__s__._E__ll_e_n___S_t_i_n_s_o__n_,__P_r_e__s_id__e_n__t____________ Phone: ___2_7__0_-_5_3__7_-_4_2__8_8_______ Email: __________e__s_t_in__s_o_n__@__s__c_r_t_c_._c_o_m_________________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: ________________________ O/O Mailing Address: ____1_0__5__B__e_d__fo__r_d__C__o_u__rt____________________________________________________________ City: ___H__o_r_s_e__C__a_v__e________________ County: ________H__a__rt___________________ State:__K__Y____ Zip: _4_2__7_4_9___ Well Data from File Well Name & #: ______P_A__Y__T_O__N___#_7___E_a__s_t_______________________________________________________________ Well Type (see table): _C__la_s__s_I_I_-_R_,__E_n__h_a_n__c_e_d__O__il__R_e__c_o_v_e__ry__(_E__O__R_)__ State Permit: ________5__5_3__6_5____________ Latitude (N): _____3__7_.1__9_3_9_0_____________ Longitude (W): _____-_8_5_._7_7_6_9_5___________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing Other: ____7_"__s_u_r_f_a__c_e__c_a__s_i_n_g____________________________________________ Total Depth (ft): __6__3__3____ Inner Casing Size (in): _4_____"__ Tubing Size (in):__2_____"___ Packer Depth (ft): _5__6__0___ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ______0_0__0_________________ Longitude (W): _____0__0_0________________ Elevation (ft): ____________ EPA GPS ID: _S_C__8_2_8__4_ Well Status (see table): __A___C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _P_r_o__d_u__c_e_d__W___a_t_e_r_s__(_P__W__)________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ _C__a_n__h__e_a__r_t_h_e___tr_i_c_k_l_in__g__s_o__u_n__d_s__o__f _p_r_o__d_u__c_e_d__w__a__te__r_s_,_f_l_o_w__i_n_g__u__n_d__e_r__g_r_a_v__it_y__p_r_e__s_s_u__re__________ _f_o_r_e__n_h_a__n_c_e_d__o__il__re__c_o_v_e__ry__. _T_h__e__s_t_o_r_a_g_e__t_a_n__k_i_s__b_e__s_id__e__th__e__in_j_e_c_t_i_o_n__w__e_ll_._T__h_e__i_n_je__c_t_io__n__w_e__ll_______ _s_h_o__w_s__c__o_r_ro__s_io__n_._T_h__e__a_n_n__u_lu__s__p_r_e_s_s_u__re__g__a_u_g__e__is__d_a__m__a_g_e__d_/_il_le__g_ib__le__. ______________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log 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_: _20_2_4._12_.1_0_1_7:_25_:4_4_-0_5_'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#: K Y S 0 9 9 0 0 Year-Month-Day: 2 0 2 4 - 1 0 - EPA Permit # (or RA): K Y I 0 4 Page 2 Of 10 24 20 2 (Cont) ________________________________________________________________________________________________ _________P_A__Y__T_O__N__#__7__E_a__s_t____________C_l_a_s_s__I_I_-R__,_E__n_h__a_n_c__e_d__O__il_R__e_c__o_v_e_r_y__(_E_O__R__)___________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_C__a__r_o_l_C__h__e_n_________________________EPA Camera ID: __S__C__8_2_8__4____________________________ Photo ID: _D__S_C__N__1_5_0__1_____Time: __7_:_5_6___a_m___ Lat (N): _____0_0__0_____________ Long (W) _____0_0__0______________ Description: _s__t_o_r_a__g__e__t_a_n__k___________________________________________________________________________ Photo ID: _D__S__C__N__1_5_0__2____Time: _7_:_5_6___a_m____ Lat (N): _____0_0_0______________ Long (W) ____0__0_0_______________ Description: _s__to__r_a__g_e___t_a_n__k__a__n__d__i_n_j_e__c_t_i_o_n___w__e__ll___________________________________________________ Photo ID: _D__S_C__N__1_5_0__3_____Time: _7_:_5_7__a__m____ Lat (N): _____0_0__0_____________ Long (W) _____0_0__0______________ Description: _i_n_j_e__c_t_i_o_n___w__e__ll__________________________________________________________________________ Photo ID: _D__S_C__N__1__5_0__4____Time: _7_:_5_8___a_m____ Lat (N): _____0__0_0_____________ Long (W) _____0_0__0______________ Description: _p_r_o__d__u_c__t_io__n___w__e_l_l_i_s__n__e__a_r_b__y___________________________________________________________ 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_.1_2_.10_1_7_:2_6:_08_-0_5_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18