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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program EPA Well ID#: F L S 1 1 3 0 0 4 0 Year-Month-Day: 2 0 2 3 - 0 4 - 3 0 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 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_l_a__F_o_y______________________ Start Time: _4_:_3_8__p__m__ ____________________________________, ____________________________________ End Time: _4_:_4_1__p_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_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__ Well Data from File R. D. SCOTT #41-5 API No. 09-113-20187 PA No. 312062 Well Name & #: ________________________________________________________________________________________ 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__0_0_2________ Latitude (N): _______3_0__.9__5_1_3__4_8_________ Longitude (W): _______-_8_7__.1__5_7__7_5_7______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15967' Other: __s_u_rf_a_c_e__c_a_s_in_g__1_0_3__/_4_"a_t__3_6_9_2_'______________________________________ 16027' 7" 16025' 3 1/2" 15431' 14348' Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; X Perforated; Top(ft) 1_5__6_9_6__'_ Bottom(ft): __1__5_8_8__0_'__ 7500 N2 gas 4400psi PW Max. Injection Pressure (psig): ________ Field Measurements and Observations 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): ____A_C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: ______N__it_r_o_g__e_n__(_N__)__G_a__s_I_n_j_e_c_t_io__n_________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _D_A_N__G_E_R__s_i_g_n_:_H__S__M__a_y__B_e__P_r_e_s_e_n_t_.._.H__a_z_a_r_d_o_u_s__O_p_e_r_a_t_io__n_s_.._.K__e_e_p__O_u_t_._.._A_u_t_h_o_r_iz_e_d__P_e_r_s_o_n_n__e_l _O_n_l_y_.._._________ _T_h__is__w_e__ll_i_s__a_c_t_iv_e__ly__in__je_c_t_i_o_n__N_i_t_r_o_g_e_n__(_N__)__G_a_s__. _________T_u_b__in_g__g_a__u_g_e_:___________4_8__0_0__p_s_i____________ _________________________________________________________P_r_o_d_u__c_t_io_n__g__a_u_g_e__: ______0__p_s_i________________ _________________________________________________________S_u__rf_a_c__e_g__a_u_g_e__: _________0__p_s_i________________ _________________________________________________________F_l_o_w__L_i_n_e__g_a_u__g_e_:____________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector 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:_32_:5_2_-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 4 0 Year-Month-Day: 2 0 2 3 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen Photographer: ______________________________________EPA Camera ID: _______S_C_8__2_8__4________________________ Photo ID: __D__S_C_N__1_3__5_2_____Time: __4_:_3_8__p__m___ Lat (N): _____N_o__G__P_S__0_0__0_____ Long (W) _____N_o__G__P_S__0_0__0______ Description: i_n_j_e_c_t_io_n__w_e__ll_, _id_e__n_ti_f_ic_a_t_i_o_n_s_i_g_n_,_D__A_N_G__E_R__s_ig__n_: _H__S__M__a_y_B__e_P__re__s_e_n_t_.._.H__a_z_a_r_d_o_u_s__O_p_e__ra_t_i_o_n_s_._..____ Photo ID: __D__S_C__N_1__3_5_3_____Time: __4_:_3_9__p__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_i_o_n__g_a_u__g_e__r_e_a_d_s__0__p_s_i_____________________________________________________________ Photo ID: __D__S_C__N_1__3_5__4____Time: __4__:3__9__p_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_5__5____Time: __4__:4__0__p_m___ Lat (N): _____N_o__G__P_S__0_0__0_____ Long (W) _____N__o__G_P__S__0_0__0_____ Description: __i_n_j_e_c_t_io__n_t_u__b_in__g_g__a_u_g_e__r_e_a__d_s__4_8_0__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__ro__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_:3_3:_21_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18