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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 7 7 0 0 0 1 Year-Month-Day: 2 0 2 3 - 0 7 - 2 7 EPA Permit # (or RA): K Y I 1 0 6 1 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _C__a_r_l _W__e_l_l_e_r_____________________ (lead),__________________________________ Start Time: _3_:_0_0______ ____________________________________, ____________________________________ End Time: _3_:_4_5______ Facility Contact Information Facility Name:_S_t_e_r_l_in__g__M__a_te__r_ia_l_s________________________________________________________________________ Street Address:_1_9_9__S__i_e_r_ra__D__r_i_v_e________________________________________________________________________ City: _V_e__r_o_n_a________________________ County: _G__a_ll_a_t_in________________________ State:_K__Y_.____ Zip: _4_1__0_9_2___ Nature of Business: _L_i_m__e_s_t_o_n_e___________________________________________________________________________ Facility Owner/Operator: _S_t_e_r_li_n_g__V_e__n_tu__re__s________________________________ Phone: _8_5_9__-5__6_7_-_7_3_0_0___________ Email: _g_k_u_h_n__h_e_i_n_@__y_a_h__o_o_._c_o_m__________________________________________________________________________ Facility Contact (if different): _R_._L_._M_a__x_w_e__ll____________________________________ Phone: _8_5__9_-_7_0_5__-6__0_8_2__________ O/O Mailing Address:1_0__0__S_i_e_r_r_a__D_r_i_v_e____________________________________________________________________ City: _V_e__r_o_n_a________________________ County: _G__a_l_la__ti_n_______________________ State:_K__Y_.____ Zip: _4_1__0_9_2___ Well Data from File Well Name & #: _In__je_c_t_i_o_n__W__e_ll_#__1________________________________________________________________________ Well Type (see table): _C__la_s__s__1______________________________________ State Permit: _N__/A_______________________ Latitude (N): _3_8_._8_3_0__0_0_3________________ Longitude (W): _-_8_4_._7_5_9_7__9_4_____________ Elevation (ft): _6_6__5_' _______ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing roof of mine Other: __________________________________________________________________ Total Depth (ft): _4_8__4_' _____ Inner Casing Size (in): _1_0__''____ Tubing Size (in):_8_'_' _______ Packer Depth (ft): _n_o__p__k_r_ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _8_3__.0__0_0_0_5_________________ Longitude (W): _-_8_4_._7_5__9_7_9__4____________ Elevation (ft): _6_6__5_' _______ EPA GPS ID: _s_x_8__1_2_3__ Well Status (see table): _A__C______ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _N__o_n_e__H__a_z_a__r_d_o_u__s_L__im__e__S__ta__b_i_li_z_e_d__P__ic__k_le__L__iq_u__o_r__S_l_u_d_g__e_________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _D__u_r_in__g__c_o_n_v__e_r_s_a_t_io__n__it__w_a__s_s__ta__te__d__th__a_t_L__e_a_c_h__a_t_e__fr_o_m___L_a__n_d_f_i_ll_m__a__y_a__ls__o__b_e__In__je__c_t_e_d_______________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/Operator Representative (Optional) UIC Inspector Name:_R__.L__. _M__a_x_w__e_l_l_________________________________ Name: _C__a_r_l _W__e_l_l_e_r__________________________________ CARL WELLER (Affiliate) Date: 2023.09.05 10:43:50 -04'00' Digitally signed by CARL WELLER (Affiliate) Signature: ___________________________________________ Signature: ___________________________________________ 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 7 7 0 0 0 1 Year-Month-Day: 2 0 2 3 - 0 7 - 2 7 EPA Permit # (or RA): K Y I 1 0 6 1 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_C_a__rl_W___e_ll_e_r___________________________EPA Camera ID: _s_x_8_1__2_3_______________________________ Photo ID: _d_s_c__0_0_2__6_7_______Time: _3_:_3_3________ Lat (N): _3_8__.8__3_0_0_5____________ Long (W) ___8__4_._7_5_9__8_2___________ Description: _C__lo_s__e__V_i_e_w__o__f_I_n_j_e_c_t_io__n__W__e_l_l_____________________________________________________________ Photo ID: _d_s_c__0_0_2__6_8_______Time: _3_:_3_4________ Lat (N): _3_8__.8__2_9_9_9____________ Long (W) _-_8_4_._7_5__9_9_0____________ Description: _V_i_e_w__o_f__In__je_c_t_io__n_W__e__ll_a_n__d__P_la__n_t____________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Owner/Operator Representative (Optional) UIC Inspector Name:_R__.L__. _M__a_x_w__e_l_l_________________________________ Name: _C__a_r_l _W__e_l_l_e_r__________________________________ Digitally signed by CARL WELLER (Affiliate) Signature: ___________________________________________ Signature: __C_A_R_L_W_E_L_L_E_R_(_A_ff_il_ia_t_e_) _Da_te:_20_23_.0_9.0_5 1_0:_43_:12_-0_4'0_0'___________ Version 2018-04-18