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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 5 7 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 0 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ___C_a__ro__l _C_h_e__n_______________(lead), _______C__a_r_la__F__o_y____________________ Start Time: _2_:_0_0__p__m__ ____________________________________, ____________________________________ End Time: _2_:_0_9__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 Well Name & #: ____S_t_._R__e_g_i_s_S__W__D_S__#__1_-_3______________________A_P__I _N_o__. _0_9__-1__1_3_-_2_0__2_0__6____P_A__N_o__. _3_1__1_6_4__3__ 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: ___________O_G____1_0__9_3_______ Latitude (N): _______3_0__.9__6_8__0_6__________ Longitude (W): ______-_8_7_._1_8__2_2__5________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; x Tubing & Packer; Cemented Injection Tubing PBTD: 6655' surface casing 10 3/4" at 2314' Other: __________________________________________________________________ Total Depth (ft): ___6_7__8_3_'__ at 6783' Inner Casing Size (in)7: _5__/_8_"___ Tubing Size (in):__________ Packer Depth (ft): _6_1__0_6__' _ Inj. Zone: Open Hole; X Perforated; Top(ft) _6__2_7_4__' _ Bottom(ft): ____6_6__6_2_'__ Max. Injection Pressure (psig): 1_8__0_0__p_s_i Field Measurements and Observations Latitude (N): _____3_0__.9__6_7__9_2____________ Longitude (W): _____-8__7_._1_8__2_3_1__1________ Elevation (ft): ____________ EPA GPS ID: _S_7_5__3_2_2__ Well Status (see table): ____A_C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _____P_r_o_d_u_c_e_d__W__a_t_e_r_s_(_P_W__)_________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ DANGER sign posted: HS May Be Present..Authorized Personnel Only..Hazardous Operations.. _____________________________________________________________________________________________________ _T_h__is__w_e__ll_i_s__a_c_t_iv_e__ly__in__je__c_ti_n_g__p_r_o_d__u_c_e_d__w__a_t_e_r_s_._______________T_u_b_i_n_g__g_a_u_g_e_:_________8_0_0__p__s_i___________ ______________________________________________________________P_r_o_d_u_c_t_io_n__g_a_u__g_e_:_____0__p_s_i______________ _P_e_rf_o_r_a_ti_o_n_s_(_T_u_s_c_a_lo_o__sa__F_o_r_m_a_t_io__n_):______________________________S__u_r_fa_c_e__g_a_u__g_e_:________0__p_s_i______________ _6_2_7_4_'_t_o__6_5_0_4_'________________________________________________F__lo_w__l_in_e__g_a_u__g_e_: _(_u_n_a_b__le__to__r_e_a_d__t_h_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._07_.0_9_1_0:_49_:3_7_-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 Year-Month-Day: 2 0 2 4 - 0 4 - EPA Permit # (or RA): F L I 0 0 Page 2 Of 5 7 3 0 1 0 2 (Cont) ________________________________________________________________________________________________ _____S__t_. _R_e__g_is__S_W__D__S__#_1__-3__________S_t_a_t_e__P_e_r_m__it__N_o__. _O_G____1__0_9_3__________A_P_I_N__o_.__0_9_-_1_1__3_-_2_0__2_0_6__________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:______C_a_r_o_l__C_h_e__n______________________EPA Camera ID: _________S_7__5_3_3__2______________________ Photo ID: ___R__IM__G__0_1_3_5_____Time: ___2_:0__6__p_m___ Lat (N): ___3__0_._9_6__7_9_2_________ Long (W) _____-_8_7__.1__8_2_3__1_1______ Description: __p_h__o_to__o_f_t_h_e__i_n_je_c_t_i_o_n__tu_b__in_g__d_o_e_s__n_o_t__s_h_o_w__a_l_l _o_f_t_h_e__g_a_u_g_e___________________________________ Photo ID: ___R__IM__G_0__1_3_5_____Time: ___2_:0__7__p_m___ Lat (N): ___3__0_._9_6__8_9_5_________ Long (W) ____-_8_7__._1_8_2__3_2__5______ Description: __p_h_o_t_o__o_f_t_h_e__s_u_r_fa_c_e__g_a_u__g_e_a__n_d_p__ro__d_u_c_t_io_n__g_a_u_g__e_, _b_o_t_h__s_h_o_w_i_n_g__0__p_s_i _________________________ Photo ID: ___R__IM__G_0__1_3_5_____Time: ___2_:_0_8__p_m___ Lat (N): ___3__0_._9_6__8_5_7_________ Long (W) _____-8__7_._1_8_2__2_0__1______ Description: __p_r_o_d_u_c_e_d__w__a_t_e_rs__m__a_n_i_fo_l_d_,_n_e__a_r_t_h_e__in_j_e_c_t_io_n__w__e_ll____________________________________________ Photo ID: ___R__IM__G_0__1_3_5_____Time: ___2_:_0_8__p_m___ Lat (N): ___3__0_._9_6__7_8__________ Long (W) -87.182178 ______________________ Description: f_l_o_w_l_in_e__g_a_u__g_e_d__o_e_s_n__o_t_d_i_s_p_la__y_t_h_e__p_r_e_s_s_u_r_e_r_e_a_d__in_g_,__n_o_n__e_e_d_l_e_a__n_d_t_h_e__g_a_u_g__e_i_s_f_i_ll_e_d_w__it_h__f_lu_i_d_s_ 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_7_.09_1_0_:5_0:_01_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18