Document gEb1Xgb5zKeeZ3yQxO4RMb69L

DownloadSearchable PDFRandom document
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 8 1 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1 EPA Permit # (or RA): F L I 0 0 5 3 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C_a_r_o_l_C_h_e__n___________________ (lead), ______C__a_r_la__F_o_y_____________________ Start Time: 1__1_:_5_7__a_m__ ____________________________________ , _______________________________________ End Time:1_2__:0__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 Well Name & #: ________B_r_a_x_t_o_n__#_2__1_-_1_________________________________________A__P_I_N__o_._0__9_1_1__3_2__0_0_3__3_____ 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_1_0___________ Latitude (N): ____3_0__.9__3_7__7_0_4__7_1_________ Longitude (W): ___-_8_7__.1__7_5__2_6__0_2_7_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing Other: __su__rf_a_c_e_c_a_s_i_n_g_9___"__@_3_8_2__9_' _________________________________________ Total Depth (ft): _1_6_0__8_4__' __ Inner Casing Size (in): 7_"_@__1_6__0_82Tubing Size (in):3___"__@_1_5_5__50 Packer Depth (ft): ________ Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5__6_9___ Bottom(ft): __1_5__7_2_8____ 7,260 PW/N 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__ TA Well Status (see table): _________ If not Active, Reported Date Last Active:___2_/_1__1_/_2__2______ Nature of Injected Fluid(s) if any:__________________________________________________________P_lu_g__S_e_t_@__1_5_,_5_3_6__' __ General Condition of the Well Site:__________________________________________________________________________ ____________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________ _T_h_e__i_n_je__c_t_io_n__w__e_l_l _h_a_s__b_e__e_n__d_i_s_c_o_n_n__e_c_t_e_d__f_r_o_m__t_h_e____________________________________________________ _p_r_o_d__u_c_e_d__w__a_t_e_r_s__in_j_e_c_t_i_o_n__li_n_e__. _P_o_o__li_n_g__f_lu_i_d_s__a_r_e______________T_u_b_i_n_g__G_a_u_g__e_: ___________0__p_s_i___________ _s_e_e__n_a__r_o_u_n_d__t_h_e__i_n_j_e_c_t_io__n_w__e_l_l.__R_e_p__a_ir_s__a_r_e__p_l_a_n_n__e_d___________P_r_o_d_u__c_ti_o_n__G_a_u__g_e_:_______0__p_s__i __________ _in__t_h_e__f_u_t_u_r_e_.__________________________________________________S_u__rf_a_c_e__G_a_u__g_e_:__________0__p_s__i __________ _______________________________________________________________F_l_o_w__L_in__e_G__a_u_g_e_:________________________ ______________________________________________________________________________________________________ ____________________________S_ee__re_v_er_s_e_fo_r_a_d_d_it_io_n_al_o_b_s_er_v_a_tio_n_s_, _co_m_m__e_nt_s_a_n_d_p_h_o_to_l_og_______________________________ UIC Inspector UIC Inspector Carol Chen Name:_______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C_H__E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_56_:5_3_-0_4_'00_'___ 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 5 - EPA Permit # (or RA): F L I 0 0 Page 2 Of 8 1 0 1 5 3 2 (Cont) ________________________________________________________________________________________________ __B_r_a_x_t_o_n__#__2_1_-_1_______________________A_P_I__N_o_.__0_9_1__1_3__2_0_0__3_3___________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen SC8284 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: __D_S__C_N__1_4_1__8_____Time: _1__1_:_5_7__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_e__d__w_a_t_e_r_s__m__a_n_i_f_o_l_d_,_i_d_e_n_t_i_fi_c_a_t_i_o_n__s_i_g_n__fo__r_t_h_e__in__je__c_ti_o_n__w__e_l_l ________________________ Photo ID: __D__S_C_N__1_4__1_9_____Time: _1__1_:_5_8__a_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_e_d__w__a_t_e_r_s_m__a__n_if_o_l_d_______________________________________________________________ Photo ID: __D__S_C_N__1_4__2_0_____Time: _1__2_:_0_0__p_m___ Lat (N): _____N_o__G__P_S__0_0__0_____ Long (W) No GPS 000 ______________________ Description: b_a__c_k_o__f_i_n_je__c_t_io_n__w__e_l_l,_d__is_c__o_n_n_e__c_t_e_d__fr_o_m___t_h_e__in__je__c_ti_o_n__l_in__e_,_p_o__o_li_n_g__f_lu__id_s__a_l_l_a_r_o__u_n_d________ Photo ID: __D__S_C__N_1__4_2_1_____Time: _1_2_:_0_0__p_m____ Lat (N): ____N__o__G_P__S__0_0_0______ Long (W) _____N_o__G__P_S__0_0__0______ Description: f_r_o_n_t__o_f_i_n_j_e_c_t_io_n__w__e_l_l,__s_h_o_w__in__g_g__a_u_g_e__r_e_a__d_in__g_s__o_n__t_u_b_i_n_g_,_s__u_r_fa__c_e__a_n_d__p_r_o_d__u_c_t_io__n__c_a_s_i_n_g_s__ Photo ID: ___D_S__C_N__1_4_2__2____Time: _1__2_:_0_1__p_m___ Lat (N): ____N__o__G_P__S__0_0_0______ Long (W) _____N_o__G__P_S__0_0__0______ Description: _c_l_o_s_e__-u_p__o__f_s_u_r_f_a_c_e__a_n__d__p_r_o_d_u__c_ti_o_n__g_a__u_g_e_s_,__re__a_d_i_n_g__0__p_s_i_________________________________ 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_.0_6._20_2_1_:57_:2_4_-0_4_'00_' ____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18