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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 0 3 3 0 0 Year-Month-Day: 2 0 2 4 - 0 4 - EPA Permit # (or RA): Page 1 Of 0 3 3 0 2 Inspector(s): ______C__a_r_o_l _C_h_e_n___________________ (lead), ______C__a_r_la__F_o_y_____________________ Start Time: 1__0_:_4_5__a_m__ ____________________________________ , _______________________________________ End Time: 1__0_:_5_0__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__r_e_it_b_u__r_n_O__p_e__ra__ti_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: ___E__s_c_a_m__b_i_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: ____E__s_c_a_m__b_i_a__________________ State:__F_L_____ Zip: __3_2__5_6_5__ Well Data from File 750LOOHU0LOOV% $3,1R 3$1R Well Name & #: ________________________________________________________________________________________ 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: ___2__*_B___7___ ______________ Latitude (N): ______3_0__.9__8_6_4__8_8__________ Longitude (W): ____-_8_7__.2__1_7__3_5_8_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing 3%7' VPDFNRYHUSHUIVVHWVWR Other: __VX__UI_D_F_H_F_D_V_L_Q_J_________WR____________________________________________ Total Depth (ft): __________ Inner Casing Size (in): ________ 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_0__.9__8_6__4_8_8____________ Longitude (W): _____-8__7_._2_1__7_2_5__8________ Elevation (ft): ____________ S75332 PA EPA GPS ID: _________ Well Status (see table): _________ 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_is__w__e_l_l _w_a__s_c_o__m__p_le__te__ly__p_lu__g_g_e_d__a__n_d__a_b_a_n__d_o_n__e_d__o_n__1_2__/_0_9_/__2_1_._____________________________________ P__lu__g_g_e_d__w__e_l_l _is__n_o__t _v_i_s_ib_l_e_,__lo_c_a__te__d__u_n_d__e_r_g_r_o_u_n_d__, _c_a_p__p_e_d__o_f_f_.____T_u_b_in_g__g_a_u_g_e_:_________________________ _O_n_s__it_e__c_a_n__o_n__ly__s_e_e__d_i_r_t-_c_o_v_e__r_e_d__la_n__d__w_i_t_h_v__e_g_e_t_a_t_i_o_n_.___________P_r_o_d_u_c_ti_o_n__g_a_u_g_e_: _____________________ _________________________________________________________________S_u_r_fa_c_e__g_a_u_g_e_:________________________ _________________________________________________________________F_l_o_w_l_in_e__g_a_u_g_e_:_______________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Carol Chen Name:_______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_20_:0_1_-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 0 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______T_._R__._M__i_ll_e_r_M__i_ll_s__#_3__4_-_4_________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:______C_a__ro__l _C_h_e__n______________________EPA Camera ID: ______S_7__5_3__3_2_________________________ Photo ID: __R_I_M__G__0_1_1__3_____Time: __1_0_:_4_6__p__m__ Lat (N): ____3_0__.9__8_6__4_8__8______ Long (W) _____-8__7_._2_1__7_2__5_8______ Description: ____P_l_u_g_g_e__d__w_e_l_l_i_s_n__o_t_v_i_s_i_b_le__,_s_e_e__d_i_r_t_-c_o__v_e_r_e_d__la__n_d_s_c__a_p_e__w__it_h__v_e_g_e_t_a__ti_o_n_._________________ 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: ___________________________________________________________________________________________ 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_:2_0:_26_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18