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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 3 0 0 3 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _____C__a_r_o_l _C_h_e_n____________________ (lead), ______C__a_r_la__F_o_y_____________________ Start Time: _9_:_5_5__a__m__ ____________________________________ , _______________________________________ End Time:1_0__:0__0__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_r_a_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__ McDavid Lands #34-2 API No. 09-113-20027 PA No. 311582 Well Name & #: ________________________________________________________________________________________ Well Type (see table): ___E__n_h_a_n__c_e_d__O__il_R__e_c_o_v_e__r_y_(_E_O__R_)______________ State Permit: ______O_G____4_9__8_____________ Latitude (N): ______3_0_._9_9__1_4__1_1__________ Longitude (W): ______-8__7_._1_6_3__1_0__3_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing PBTD: 15564' Other: ____s_u_r_f_a_c_e__c_a__s_in__g_1__0__3_/_4__"_a_t__3_5_6__2_'______________________________ Total Depth (ft): __1_5__6_7__7_'_ 7" 15677' 15100' Inner Casing Size (in): ________ Tubing Size (in):_3__1_/_2__"___ Packer Depth (ft): _1_5_0__6_0_'_ 7500 N2 gas Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5__2_1_7__' Bottom(ft): _1__5_3__0_0_'___ Max. Injection Pressure (psig):44_0__0_p_s_i _P_W 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): ___T_A_____ If not Active, Reported Date Last Active: ___9__/_0_7_/__2_1_______ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): __T_e_m__p_o_r_a_r_i_ly__A_b__a_n_d_o__n_e_d__(_T_A_)_________________________ This injection well has been inactive since 9/20/21, temporarily abandoned. _____________________________________________________________________________________________________ T__h_e__tu__b_i_n_g__g_a_u_g_e__h__a_s__re__ta__in_e__d__2_0_0__0__p_s_i_a_f_t_e_r__th__e________T_u__b_in_g__G_a__u_g_e_:__________2__0_0__0__p_s_i____________ _w__e_ll_w__a_s__s_h_u__t_d_o__w_n_.__A_T__-s_k__il_le_t__w_a__s_i_n_s_t_a_l_le__d_o__n__th__e______P__ro_d__u_c_t_io_n__G_a__u_g_e_:_______0__p_s_i________________ _f_lo_w___li_n_e__t_o_s_h__u_t_-o__ff__in_j_e_c_t_i_o_n_._T__h_e__w_e_l_l_p_a__s_s_e_d__a___________S_u_r_f_a_c_e__G_a_u_g_e__: ________0__p__s_i ________________ _m__e__c_h_a_n_i_c_a_l__in_t_e_g__ri_t_y_t_e_s_t__o_n__3_/_0__9_/_2_3__.___________________F_lo__w__L_in_e__G_a__u_g_e_:_______0__p__s_i________________ _____________________________________________________________________________________________________ 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:_51_:1_9_-0_4_'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#: F L S 1 1 3 0 0 3 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______M__c_D_a__v_id__L_a__n_d_s__#_3__4_-_2__________________O_G____4_9__8_________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: ______C_a__rl_a__F_o_y_________________ EPA Camera ID:___________S_C__8_2__8_4___________________________ Photo ID: _D__S_C_N__1_3__7_5______Time: __9__:5__7__a_m___ Lat (N): ____N_o__G__P_S__0_0__0______ Long (W) ____N__o__G_P__S__0_0_0_______ Description: ____s_u_r_f_a_c_e__g_a__u_g_e__r_e_a_d__s_0__p__s_i _____________________________________________________________ Photo ID: _D__S_C__N_1__3_7_6______Time: __9_:_5_8__a__m___ Lat (N): ____N_o__G__P_S__0_0__0______ Long (W) _____N_o__G__P_S__0_0__0______ Description: ____p_r_o_d_u__c_t_io_n__g__a_u_g_e__a_n__d__fl_o_w__l_in__e__g_a_u_g__e_r_e_a__d__0__p_s_i_______________________________________ Photo ID: _D__S_C__N_1__3_7_7______Time: __9_:_5_8__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__in_g__g_a__u_g_e__r_e_a_d__s_2__0_0__0__p_s_i__________________________________________________________ Photo ID: __D_S__C_N__1_3_7__8_____Time: __1_0_:_0_0__a__m__ Lat (N): ____N_o__G__P_S__0_0__0______ Long (W) ____N__o__G_P_S__0__0_0_______ Description: ____m__a_n_i_f_o_ld__f_l_o_w__l_in__e_g__a_u_g_e__r_e_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_1:_46_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18