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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 3 7 Year-Month-Day: 2 0 2 4 - 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__ro__l _C_h_e_n___________________ (lead), ________C_a__rl_a_F__o_y___________________ Start Time: _3_:_4_0__p_m___ ____________________________________ , _______________________________________ End Time: _3_:_4_3__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________________________________________________________ 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 & #: __________J_._E__. _J_a_c_k_s_o__n_#__4_0__-2_______________A_P_I__N_o_.__0_9_-_1_1__3_-_2_0__1_3__3_____P_A__N_o__. _3_0__2_9__9_0____ 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____7_0__6______________ Latitude (N): _______3_0_._9_6__7_1__8_3_________ Longitude (W): _______-8__7_._2_0_8__4_3__2______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15659' Other: ___s_u_r_f_a_c_e_c_a_s_i_n_g_9__5_/_8_"_a_t__3_5_9_6_'_____________________________________ 15682' 15300' Total Depth (ft): _1__5_6__8_7_'__ Inner Casing Size (in): 7_"_______ Tubing Size (in):_3__1_/_2_"____ Packer Depth (ft): _1_5__3_0__0_' Inj. Zone: Open Hole; X Perforated; Top(ft) 1__5_4_6__8_'_ Bottom(ft): __1_5__5_5_0__' __ Max. Injection P7r5es0s0uNre2(pgasisg):4_4_0_0_p_s_i_P_W Field Measurements and Observations Latitude (N): _____3__0_._9_6__7_2__0_3__________ Longitude (W): ______-_8_7__.2__0_8_5__0_8_______ Elevation (ft): ____________ EPA GPS ID: _S_7_5__3_3__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): ______________________________________________________ _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__rd__o_u_s__O_p__e_r_a_t_io__n_s_._.._K_e__e_p__O_u__t._..____________________________ _In__je_c__ti_o_n__w__e_ll__is__a_c_t_i_v_e_ly__i_n_j_e_c_t_in_g__p__ro__d_u_c_e__d_f_l_u_i_d_s_.____________T_u_b__in_g__g_a_u_g_e__: _________2_7__0_0__p_s_i_________ ______________________________________________________________P_r_o_d_u_c__ti_o_n__g_a_u_g_e_:______5_0__p__s_i ___________ ______________________________________________________________S_u_r_f_a_c_e__g_a_u_g_e_:_________5_0__p__s_i___________ ______________________________________________________________F_l_o_w__li_n_e__g_a_u_g_e_:_________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log U IC 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_: _20_2_4._07_.0_9_1_0:_42_:3_5_-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 7 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______J_._E__. _J_a_c_k_s_o__n__#_4_0__-2_____________S__ta__te__P__e_r_m__it__N_o_.__O_G____7_0__6____________A_P__I _N_o__. _0_9__1_1_3__2_0__1_3__3_____ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_______C_a__ro__l _C_h_e__n_____________________EPA Camera ID: _______S__7_5_3__3_2________________________ Photo ID: ___R__IM__G__0_1__6_8____Time: __3__:4__0__p_m___ Lat (N): ___3_0_._9_6__7_2_0_2_________ Long (W) _____-8_7__.2__0_8_7_6__6_______ Description: _i_n_je__c_t_io_n__w__e_l_l,_w__e_l_l_i_d_e_n_t_i_fi_c_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_r_e_s_e_n__t...__H__a_z_a_r_d_o__u_s_._.___ Photo ID: ___R__IM__G__0_1__6_9____Time: __3__:4__2__p_m___ Lat (N): ___3_0__.9__6_7_2_4__5________ Long (W) _____-8__7_.2__0_8_5__2_3_______ Description: _s_u_r_f_a_c_e__g_a__u_g_e__r_e_a_d__s_5__0__p_s_i_,_p_r_o_d__u_c_t_io__n_g__a_u_g_e__a__ls_o__r_e_a_d__s_5__0__p_s_i__________________________ Photo ID: ___R__IM__G__0_1__7_0____Time: ___3_:_4_2__p_m___ Lat (N): ___3__0_.9__6_7_2__0_3________ Long (W) _____-8_7__.2__0_8_5_0__8_______ Description: _tu__b_in__g__g_a_u_g_e__r_e_a__d_s__2_7_0__0__p_s_i______________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ U IC 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_:4_3:_00_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18