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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 8 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_r_o_l_C_h_e__n__________________ (lead), ______C_a__rl_a__F_o_y_____________________ Start Time: _3_:_1_0__p__m__ ____________________________________ , _______________________________________ End Time: _3_:_1_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 Name & #: __________J_. _E_._J_a__c_k_s_o_n__#__4_0_-_4_A_____________A_P__I _N_o__. _0_9__-1__1_3_-_2_0__1_0__0_______P_A__N__o_._3_1__1_5__9_8___ Well Type (see table): __E_n_h_a__n_c_e_d__O__il__R_e_c_o__v_e_r_y_(_E_O__R_)________________ OG_627 State Permit: __________________________ Latitude (N): ________3_0_._9_5__9_8__8_9________ Longitude (W): ________-8__7_._2_0_0__0_0__8_____ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15778' surface casing 9 5/8" at 3744' Other: __________________________________________________________________ 15828' 5 1/2" 15828' 2 7/8" 15510' 15510' Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; X Perforated; Top(ft) 1_5__6_5__6_'_ Bottom(ft): __1_5_7__1_0__' __ 7500 N2 gas 4400psi PW Max. Injection Pressure (psig): ________ Well Data from File Field Measurements and Observations Latitude (N): _____3_0__.9_5__9_8_9__3___________ Longitude (W): ______-_8_7_._2_0_0__0_3_________ Elevation (ft): ____________ EPA GPS ID: _S_7_5__3_2_2__ Well Status (see table): ___T__A____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ D__A_N_G__E_R__s_i_g_n__i_s_p__o_s_t_e_d_:_H___S__M__a_y__B_e__P_r_e_s_e__n_t_.._A_u_t_h_o__ri_z_e_d__P_e__rs__o_n_n_e__l _O_n__ly_._.H__a_z_a_r_d_o__u_s__O_p_e__ra__ti_o_n__s_.._.____ _T_h_i_s__w_e__ll_i_s__in_a__c_t_iv_e_.__A_l_l _th__e__g_a_u_g__e_s__re__a_d__0__p_s_i_._____________T_u__b_in_g__g_a_u__g_e_:_________0__p_s_i_______________ _A__r_e_d__f_la_g__w__a_s__a_t_t_a_c_h_e_d__t_o__t_h_e__w_e__ll_,_i_n_d_i_c_a_t_in__g__th__a_t_________P_r_o_d__u_c_ti_o_n__g_a_u_g_e__: _____0__p_s_i_______________ _r_e_p__a_ir_s__a_r_e__n_e_e__d_e_d_.________________________________________S__u_r_fa_c_e__g_a_u__g_e_: ________0__p_s_i_______________ _A__s_i_g_n__o_n__t_h_e__w__e_ll__p_r_o_v_id__e_s__w_e__ll_i_d_e_n__ti_f_ic_a__ti_o_n__. _____________F__lo_w__l_in_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._06_.2_0_2_1:_31_:5_1_-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 8 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_-_4_A____________S_t_a_t_e__P_e_r_m__i_t_N__o_._O__G___6__2_7___________A__P_I_N__o_._0__9_1_1__3_2__0_1_0__0_______ _____________________________________________________________________________________________________ ___________________________________________P__e_r_f_o_r_a_t_io_n__s_(_S__m_a__c_k_o_v_e__r_F_o__rm__a__ti_o_n_)_:_____________________ ___________________________________________1_5_6__5_6__' _to__1__5_6__6_6_'_(_4__S_P_F_)__1_/_1__5_/_1__9_7_4______________________ ___________________________________________1_5_6__5_6__' _to__1__5_6_6__6_'_(_4_S__P_F_)__1_0_/__2_8_/_2__0_1__2____________________ ___________________________________________1_5_7__0_0__' _to__1__5_7_1__0_'_(_4_S__P_F_)__5_/_0__1_/_1_9__7_4______________________ __________________________________________1__5_7__0_0_'__to__1__5_7_1__0_'_(_4_S__P_F_)__1_0_/_2__8_/_2__0_1__2____________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen S75332 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: __R_I_M__G_0_1__5_7______Time: ___3_:1__0__p_m___ Lat (N): ____3_0_._9_5_6__4_2_2________ Long (W) ____-_8_7_._1_8_4__0_1_5________ injection well, well identification sign, DANGER sign posted: HS May Be Present... Description: ___________________________________________________________________________________________ Photo ID: __R_I_M__G_0_1__5_8______Time: ___3_:1__1__p_m___ Lat (N): ____3_0_._9_5_9__8_8_8________ Long (W) ____-_8_7_._2_0_0__1_2_2________ Description: _t_u_b__in__g_g__a_u_g_e__r_e_a_d__s_0__p__s_i_________________________________________________________________ Photo ID: __R__IM__G__0_1_5_9______Time: ___3_:1__2__p_m___ Lat (N): ____3_0_._9_5_9__8_9_3________ Long (W) ____-8__7_.2__0_0_0__3_________ Description: _s_u__r_fa__c_e__g_a_u_g_e__r_e_a__d_s__0__p_s_i________________________________________________________________ Photo ID: __R__IM__G__0_1_6_0______Time: __3__:1__2_p__m___ Lat (N): ___3__0_._9_5_9__8_6_________ Long (W) ____-8_7__.2__0_0_0_3__8________ Description: _p_r_o__d_u_c_t_i_o_n__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_:3_2:_19_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18