Document gE8a3N6npjgEknLe2r4gOVqXL

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 1 1 3 0 0 Year-Month-Day: 2 0 2 4 - 0 5 - EPA Permit # (or RA): Page 1 Of 2 0 0 1 2 Inspector(s): ______C_a_r_o_l_C_h__e_n___________________ (lead), _______C_a__rl_a__F_o_y____________________ Start Time: 1__1_:_2_5__a__m_ ____________________________________ , _______________________________________ End Time: 1__1_:_3_1__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__re__it_b_u__rn__O__p_e_r_a_t_i_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: ___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 & #: __R_u__b_y__K_e_n__t_#_1__8_-_2_______________A_P_I_N__o_.__0_9_1__1_3__2_0_0__6_5_____P_A__N_o__. _3_1__1_5__9_1________________ 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____5_6__9____________ Latitude (N): _____3_0_._9_4__4_1__7_5___________ Longitude (W): _____-_8_7__._1_5_2__1_5__5_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15836' Smackover perfs 7 sets Other: __s_u_r_f_a_c_e__c_a_s_i_n_g__1_0__3__/_4_"__3_8_3__0_'___________________________________ Total Depth (ft): _1_5__9_3_0__' __ Inner Casing Size (in):7_"_1__5_9__1_2' Tubing Size 2 7/8" 15467' (in):__________ Packer Depth (ft): 1_5_3__4_3_' __ Inj. Zone: Open Hole; X Perforated; Top(ft) 1__5_5_0__4_'_ Bottom(ft): __1_5__7_5_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: ___P_r_o__d_u_c_e_d__W__a__te__rs__(_P_W__)_________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ 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__rd__o_u_s__O_p__e_r_a_t_io_n__s_.._._K_e_e__p_O__u_t_._. ______________________________ ___"_T_-_s_k_i_ll_e_t_w__a_s__in__s_e_r_t_e_d__o_n__t_h_e__N_i_tr_o__g_e_n__(_N__)_g__a_s_l_i_n_e______T_u__b_in__g_G__a_u_g_e_:__________6_0_0__p__s_i____________ _t_o__s_to__p_g__a_s__in_j_e_c_t_i_o_n_._______________________________________P_r_o_d_u_c_t_io_n__G__a_u_g_e_:______0__p_s_i_______________ ____________________________________________________________S_u_r_f_a_c_e__G_a_u__g_e_: ________0__p_s_i_______________ ____________________________________________________________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 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._06_.2_0_2_1:_45_:1_4_-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 2 0 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______R__u_b_y__K_e__n_t_#__1_8__-2________________O_G____5_6__9_______________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer: _______C_a_r_l_a__F_o_y________________ EPA Camera ID:__________S_C__8_2_8__4____________________________ Photo ID: ___D_S__C_N__1_4__1_4____Time: _1__1_:_3_0__a_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_l_l,__id_e__n_t_if_i_c_a_t_io_n__s_i_g_n__, _D_A__N_G__E_R__s_i_g_n_:_H___S__M__a_y_b__e__P_r_e_s_e_n__t._._.K__e_e_p__O__u_t_.._._________ Photo ID: ___D_S__C_N__1_4_1__5____Time: __1_1_:_3_1__a__m__ Lat (N): ___N_o__G__P_S__0_0__0_______ Long (W) ___N__o__G_P_S__0__0_0________ Description: __tu__b_i_n_g__g_a_u_g__e__re__a_d_s__6_0__0__p_s_i______________________________________________________________ Photo ID: ___D_S__C_N__1_4__1_6____Time: _1__1_:_3_1__a_m___ Lat (N): __N__o__G_P__S__0_0__0_______ Long (W) ___N_o__G__P_S__0_0__0________ Description: __p_h_o_t_o__o_f____"_T_-_s_k_i_ll_e_t__w_a__s_i_n_s_e_r_t_e_d__o_n__t_h_e__N__it_r_o_g_e__n_(_N___)_g_a__s_l_in__e___________________________ Photo ID: ___D_S_C__N_1__4_1__7____Time: _1__1_:_3_1__a_m___ Lat (N): __N__o_G__P_S__0__0_0________ Long (W) __N__o__G_P__S__0_0__0________ Description: _p__ro__d_u_c_t_i_o_n__g_a_u__g_e__re__a_d_s__0__p_s_i__a_n_d__s_u_r_f_a_c_e__g_a__u_g_e__r_e_a_d__s_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_:4_5:_42_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18