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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#: K Y S 0 9 9 0 0 1 2 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 EPA Permit # (or RA): K Y I 0 6 6 3 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ____C__a_r_o_l__C_h__e_n__________________ (lead),__________________________________ Start Time: 8__:_1_9__a__m__ ____________________________________, ____________________________________ End Time: 8__:_2_9__a__m__ Facility Contact Information Facility Name:_______L__o_g_s_d__o_n__V__a_ll_e_y__O__i_l _C_o__.,__In__c_.______________________________________________________ Street Address:_____1__0_5__B__e_d_f_o_r_d__C__o_u_r_t_________________________________________________________________ City: ___H__o_r_s__e__C__a_v_e________________ County: ______H__a_r_t_____________________ State:___K_Y____ Zip: _4__2_7__4_9__ Nature of Business: _______o_i_l _p_r_o__d_u_c__ti_o__n________________________________________________________________ Facility Owner/Operator: ______M__s_.__E_l_le__n__S__ti_n_s__o_n__,_P__r_e_s_i_d_e__n_t____________ Phone: ____2_7_0__-5_3__7_-_4_2_8_8________ Email: ____e__s_t_in__s_o__n_@___s_c_r_t_c_._c_o__m______________________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: ________________________ O/O Mailing Address: _____1_0__5__B__e_d_f_o__rd___C_o__u_r_t___________________________________________________________ City: ____H_o__r_s_e__C_a__v_e________________ County: ________H_a__rt____________________ State:___K_Y____ Zip: __4_2_7__4_9__ Well Data from File Well Name & #: ______C_L__A__R__E_N__C__E__W___I_L_S__O__N__#__3_______________________________________________________ Well Type (see table): _C__la_s__s_I_I_-_D_,__P_r_o_d__u_c_e__d_W___a_t_e_r_s__D_i_s_p_o__s_a_l______ State Permit: ____8_7_4__3_7_________________ Latitude (N): _____3__7_.1__7_8_6_5_____________ Longitude (W): ___-_8_5__.7_8__8_0_1____________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing Other: __________________________________________________________________ Total Depth (ft): __7__6_4_____ Inner Casing Size (in): _4____"___ Tubing Size (in):_2______"___ Packer Depth (ft): _6_6__8____ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _____0__0_0__________________ Longitude (W): ____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: _P__ro__d_u__c_e__d__W__a__te__r_s__(P__W___)_______________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _A__g_r_o__u_p__o__f_s__to__r_a_g_e___ta__n_k_s__a__r_e__n_e__a_r__th__e__i_n_j_e_c_t_i_o_n__w__e__ll_. _T__h_e__a__c_t_iv__e__in__je__c_t_io__n__w__e_l_l _i_s__fo__r________ _p_r_o_d__u_c__e_d__w__a_t_e__rs__d__is__p_o__s_a_l_._C__a__n__h_e__a_r__th__e__t_r_ic_k__li_n_g__s__o_u__n_d_s__o__f_i_n_j_e_c__ti_o_n___d_i_s_p_o__s_a_l_,_f_l_o_w__i_n_g_____ _u_n__d_e_r__g_r_a_v_i_ty__i_n_j_e_c_t_io__n__p_r_e_s_s__u_r_e_._T__h_e__a_n__n_u_l_u_s__g_a__u_g_e__i_s__d_a_m__a__g_e_d__/i_ll_e_g__ib_l_e_.__T_h_e__i_n_j_e_c_t_io__n__w_e__ll_____ _s_h_o__w_s__c__o_r_ro__s_io__n_.___________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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._12_.1_0_1_7:_26_:4_2_-0_5_'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#: K Y S 0 9 9 0 0 Year-Month-Day: 2 0 2 4 - 1 0 - EPA Permit # (or RA): K Y I 0 6 Page 2 Of 12 24 63 2 (Cont) ________________________________________________________________________________________________ ________C__L_A__R__E_N__C__E__W__I_L_S__O__N__#_3___________C__l_a_s_s__I_I-_D___P_r_o_d__u_c_e_d__W___a_t_e_r_s__D_i_s_p_o__s_a_l__________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_C__a_r_o_l__C__h_e_n__________________________EPA Camera ID: __S_C__8__2_8_4_____________________________ Photo ID: _D__S_C__N__1_5_0__5_____Time: _8__:_1_9__a__m___ Lat (N): _____0__0__0____________ Long (W) _____0__0_0______________ Description: _g__r_o_u__p__o__f__s_t_o__r_a_g__e___ta__n__k_s__,_a__t__a__f_a__r_th__e__r__d_i_s_t_a__n_c__e__________________________________ Photo ID: _D__S_C__N__1__5_0__6____Time: _8_:_1_9___a_m____ Lat (N): _____0__0__0____________ Long (W) _____0__0__0_____________ Description: _c__lo__s_e__r__t_o__t_h__e__f_r_o__n_t_s__id__e__o__f__th__e___s_t_o__r_a_g__e__t_a__n_k__s____________________________________ Photo ID: _D__S_C__N__1_5_0__7_____Time: _8_:_2__0__a__m___ Lat (N): _____0__0__0____________ Long (W) _____0__0__0_____________ Description: _b_a__c__k_s__id__e__o__f__t_h_e___s_t_o__r_a_g__e__t_a__n__k_s_____________________________________________________ Photo ID: _D__S_C__N__1__5_0__8____Time: _8_:_2_1___a_m____ Lat (N): ______0_0__0____________ Long (W) ______0_0__0_____________ Description: _i_n_j_e__c_t_i_o_n___w__e_l_l__________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ UIC Inspector UIC Inspector Carol Chen Name:______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.1_2_.10_1_7_:2_7:_07_-0_5_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18