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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#: F L S 1 1 3 0 0 7 4 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 4 4 Page 1 Of 2 Inspector(s): ______C_a_r_o_l_C_h__e_n___________________ (lead), _______C_a_r_l_a_F__o_y____________________ Start Time: _1_0__:2__0__a_m__ ____________________________________ , _______________________________________ End Time: _1_0_:_3_2__a__m_ Facility Contact Information 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__re__it_b_u_r_n__O__p_e_r_a_t_i_n_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__ Well Data from File Well Name & #: _________M_c__D_a_v_i_d__L_a_n__d_s__E_t_a_l_#__3_7_-_5______________________________________________________ Well Type (see table): ____E_n_h__a_n_c_e__d__O_i_l _R_e__c_o_v_e_r_y__(E__O_R__)_____________ State Permit: ___O__G___1__3_1__4_-_H____________ Latitude (N): ______3__0_._9_9__4_8__6_1_________ Longitude (W): _______-_8_7_._1_8__6_2__1_9______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 18806 feet Other: _______s_u_r_f_a_c_e__c_a_s_i_n_g______________________________________________ 18806 7" @16878 7" @ 0 - 12822 3"@ 16408 Baker FB Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): __@_1_6_0_4_5_ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ______3_0_._9_9_4__8_8_3___________ Longitude (W): _______-8_7__.1__8_6_0__5_8_______ Elevation (ft): ____________ EPA GPS ID: _S__7_5_3_3__2_ Well Status (see table): ___N__C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): __T_h_i_s__w_e_l_l_i_s_a__n__a_c_t_iv_e__p__ro__d_u_c_e__r,__n_o_t_c__o_n_v_e_r_t_e_d________ _to__i_n_j_e_c_t_io_n__. _T_h_i_s__w_e_l_l_i_s_u__ti_l_iz_i_n_g__n_it_r_o_g_e__n__to__i_n_c_r_e_a_s_e__t_h_e__f_o_r_m__a_t_io__n_p__r_e_s_s_u_r_e__o_f_______________________ _th_e__S_m__a_c_k_o__v_e_r_F_o_r_m__a_t_io_n__. ____________________________________T_u_b__in_g__g_a_u_g_e__: _______0__p__s_i _______________ _____________________________________________________________P_r_o_d_u_c__ti_o_n__g_a_u_g_e_:____2_2__0_0__p__s_i ___________ _____________________________________________________________S_u_r_f_a_c_e__g_a_u_g_e_:_______0__p_s_i________________ _____________________________________________________________F_lo__w__li_n_e__g_a_u_g_e_:__________________________ _____________________________________________________________________________________________________ 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_: 2_0_24_.0_6_.20_2_1_:4_1:_43_-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 7 4 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 4 4 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______M__c__D_a_v_i_d__L_a_n__d_s__E_t_a_l_#__3_7_-_5_____________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _P__h_o_t_o_I_D_:__R__IM__G_0__1_1_0___T_i_m__e_:_1_0__:2_4__a_m____L_a_t__(__N_)_: __3_0_._9_9_4__8_8_3___________L__o_n_g__(_W__)_:__-_8_7_._1_8_6__0_5_8_________ _________________a_n_n_u_l_a_r_p_r_e_s_s_u__re__g_a_u_g__e_______________________________________________________________ _P_h_o_t_o__ID__: __R_I_M_G__0_1_1__1___T_i_m__e_:_1_0__:2_8__a_m____L_a_t__(__N_)_: _3__0_._9_9_4_8__7_8____________L_o_n_g__(__W__):__-_8_7__.1_8__6_0_7__________ close-up view of production well _____________________________________________________________________________________________________ _P_h__o_to__I_D_:__R_I_M_G__0_1_1__2___T_i_m__e_:_1_0__:3_2__a_m____L_a__t _(__N_)_:_3__0_._9_9_4__4_0_2____________L_o_n_g__(__W__):__-_8_7__.1_8__6_1_5__8________ sign showing identification of the production well _____________________________________________________________________________________________________ Photo Log Carol Chen Photographer: ______________________________________EPA Camera ID: ________S_7__5_3_3__2_______________________ Photo ID: ____R_I_M__G_0_1__0_4____Time: _1__0_:_2_1__a_m___ Lat (N): ___3_0__.9__9_4_9_3__8________ Long (W) ___-_8_7_._1_8_6__1_0_3_________ Description: ________p_h_o_t_o_o__f _t_h_e_p__ro_d__u_c_t_io_n__w_e__ll_, _fa__rt_h_e_r__b_a_c_k______________________________________________ Photo ID: ____R_I_M__G_0_1__0_5____Time: __1_0_:_2_1__a_m___ Lat (N): ___3_0__.9__9_4_9_2__8________ Long (W) ___-_8_7_._1_8_6__0_6_7_________ Description: ________s_u_r_f_a_c_e__g_a_u_g_e_______________________________________________________________________ Photo ID: ____R_I_M__G_0_1__0_6____Time: _1__0_:_2_2__a_m___ Lat (N): ___3_0__.9_9__4_9_2__3________ Long (W) ___-_8_7_._1_8__6_0_6_2_________ adjustable pressure meter Description: ___________________________________________________________________________________________ Photo ID: ____R_I_M__G_0_1__0_7____Time: __1_0_:_2_2__a_m___ Lat (N): ___3_0__.9_9__4_8_9__6________ Long (W) ___-_8_7_._1_8_6__0_7__________ tubing gauge - is difficult to read the gauge in this photo, too grayish Description: ___________________________________________________________________________________________ Photo ID: ____R_I_M__G_0_1__0_8____Time: __1_0_:_2_3__a_m___ Lat (N): ___3__0_.9__9_4_9__7_2________ Long (W) ___-_8_7_._1_8_6__1_2_2_________ lower portion of the wellhead Description: ___________________________________________________________________________________________ Photo ID: ____R_I_M__G_0__1_0_9____Time: __1_0_:_2_4__a_m___ Lat (N): ___3_0__.9__9_4_8_9__2________ Long (W) ___-_8_7_._1_8_6__0_8__________ Description: _________a_n_n_u__la_r__p_re__s_s_u_r_e_g_a__u_g_e_____________________________________________________________ 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_t_e:_2_0_24_.0_6_.2_0_2_1_:4_2:_0_8_-0_4_'0_0'_ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18