Document jNzG0LDXZMnDMLQ2mNdYMKpEy

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 6 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__r_la__F_o_y_____________________ Start Time: _3_:_2__6__p_m__ ____________________________________, ____________________________________ End Time: _3_:_3_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 St. Regis Paper Company (SRPC) #39-1 API No. 09-113-20051 PA No. 311589 Well Name & #: ________________________________________________________________________________________ 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_)______________ State Permit: _____O_G____5_4__1______________ Latitude (N): ______3_0__.9__6_3_6__6_1__________ Longitude (W): _______-8__7_._1_9__2_1__3_6______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15721' Other: ____s_u_r_fa__c_e__c_a_s_i_n_g__1_0__3__/_4_"__a_t_3__6_7_8__' ______________________________ Total Depth (ft): _1_5_8__0_5__' __ Inner Casing Size (in): 7" 15805' ________ Tubing Size (in):3__1_/__2_"__1_5_29P5a' cker Depth (ft): 1__5_4__1_1_'_ 7500 N2 gas Inj. Zone: Open Hole; X Perforated; Top(ft) 1__5_4__7_3_'_ Bottom(ft): _1__5_6_1__8_'___ Max. Injection Pressure (psig):4_4_0_0_p_s_i_P_W Field Measurements and Observations Latitude (N): _____3_0_._9_6__3_3__4_2___________ Longitude (W): _____-_8_7_._1_9__2_2__1_5________ 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__ro__d_u_c_e__d__W_a__te__r_s____________________________________________________ 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...__A_u__th__o_r_iz_e__d_P__e_r_s_o_n_n__e_l._._.H__a_z_a_r_d_o__u_s__O_p_e__ra__ti_o_n_s__.._.K__e_e_p__O__u_t________ _W__e_l_l _is__a_c_t_i_v_e_l_y_i_n_je__c_t_in_g__p_r_o_d__u_c_e_d__f_l_u_id__s_.___________________T_u_b__in_g__g_a_u_g__e_: ________2__0_0_0__p_s_i____________ _P_e_r_f_o_ra__ti_o_n_s_(_S_m_a__ck_o__ve_r__F_o_rm__a_t_io_n_)_:____________________________P__ro_d__u_c_ti_o_n__g_a_u_g_e__: ____0__p_s_i________________ _1_5_4_7__3_' _to__1_5_5_3_8__' _(4_S_P__F_) _8_/_3_1_/_1_9_7_2_____________________________S__u_r_fa_c_e__g_a_u__g_e_:_______0__p_s_i________________ _1_5_5_6_4__' _to__1_5_5_7_0__' (_4_S_P_F_)__6_/_2_8_/_1_9_7_4_____________________________F__lo_w__l_in_e__g_a_u__g_e_:__________________________ _1_5_6_1_0__' t_o__1_5_6_1_8_'_(_4_S_P_F_)_6_/_2_8__/_1_9_7_2______________________________________________________________________ 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:_28_:5_9_-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 6 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_______C_a_r_o__l _C_h_e__n_____________________EPA Camera ID: _______S__7_5_3__3_2________________________ Photo ID: ___R_I_M__G_0_1__6_3_____Time: __3_:_2_6__p_m____ Lat (N): ___3_0__.9__6_3_5_8__6________ Long (W) __-_8_7_._1_9_2__6_0_8__________ Description: ___w_e_l_l _id__e_n_t_if_ic_a_t_i_o_n__s_ig_n__a_t_f_r_o_n_t_o_f__p_r_o_p_e_r_ty___________________________________________________ Photo ID: ___R_I_M__G_0__1_6_4_____Time: __3_:_2_7__p_m____ Lat (N): ____3_0_._9_6_3__6_4_3________ Long (W) __-_8_7__.1_9__2_2_1__3_________ injection well, DANGER sign: HS May Be Present...Hazardous Operations...Keep Out...Hot Piping... Description: ___________________________________________________________________________________________ Photo ID: ___R__IM__G__0_1_6_5_____Time: __3_:_2_8__p_m____ Lat (N): ____3_0_._9_6_3__6_3_7________ Long (W) ___-8__7_.1__9_2_2__3_5_________ Description: _s_u_r_f_a_c_e__g_a_u_g_e__0__p_s_i________________________________________________________________________ Photo ID: ___R__IM__G_0__1_6_6_____Time: ___3_:_2_8__p_m___ Lat (N): ____3_0_._9_6__3_6_5_7________ Long (W) ___-_8_7_._1_9_2__1_9_8_________ Description: _p__ro_d__u_c_ti_o_n__g_a_u_g_e__s_0__p_s_i____________________________________________________________________ Photo ID: ___R__IM__G__0_1_6_7_____Time: ___3_:_2_9__p_m___ Lat (N): ____3_0__.9_6__3_3_4__2_______ Long (W) ___-_8_7__.1_9__2_2_1__5________ Description: _i_n_j_e_c_t_io_n__t_u_b_in__g_g_a__u_g_e__re_a__d_s_2__0_0_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_:29_:2_4_-0_4_'00_' ____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18