Document jZMYqKOn3kLNxMjmJpJnQx32
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 5 9
Year-Month-Day: 2 0 2 2 - 0 9 - 1 3
EPA Permit # (or RA):
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k;.: spector(s): Page Cirillo ___________________ (lead), Jason Rose_____________________________Start Time: 10:03 AM___
____________________________________, ____________________________________ End Time: 10:10 AM ___
Facility Contact Information
Facility Name: Blackjack Plant ____________________________________________________________________________ Street Address: 4940 Blackjack Plant Road ___________________________________________________________________ City:Jay ____________________________ County: Santa Rosa _____________________ State:FL______ Zip:32535 ___ Nature of Business: Oil and gas production __________________________________________________________________ Facility Owner/Operator: Black Creek Energy, LLC ____________________________ Phone: (601) 431-5386 __________ Email: harris.butler@butlerroyals.com ______________________________________________________________________ Facility Contact (if different): Michael Wetzel ___________________________________ Phone: (805) 324-6271 __________ O/O Mailing Address: 140 Virginia Street, Suite 402 __________________________________________________________ City: Richmond ______________________ County: NA_____________________________ State: VA _____ Zip: 23209 ___
Well Data from File
Well Name & #: Black Jack Creek SWDS 1-1 #24-1A
Well Type (see table): Disposal _______________________________________ State Permit: API # 0911320060 _________
Latitude (N): 30.846795N ______________ Longitude (W): -87.094177W ___________ Elevation (ft): 115.9' ______
Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing
PBTD 7400'
Other: __________________________________________________________________
Total Depth (ft): 7480' _____ Inner Casing Size (in):7" ______ Tubing Size (in): 2 - 7/8" __ Packer Depth (ft): 5695'___
Inj. Zone: Open Hole; Perforated; Top(ft): 6556' ___ Bottom(ft): 6680' _____ Max. Injection Pressure (psig): 1,800 psi
Field Measurements and Observations
Latitude (N): 30.846830N ______________ Longitude (W): -87.094214W ___________ Elevation (ft): NA _________ EPA GPS ID: PG No. 3358766066 ________ Well Status (see table): SI If not Active, Reported Date Last Active: Operator did not provide. ___ Nature of Injected Fluid(s) if any: __________________________________________________________________________
General Condition of the Well Site: _________________________________________________________________________
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Notes & Comments (include discrepancies from database values): DEP indicated the disposal well is used as needed depending on
when the plant is down. The operator confirmed this statement. The observed pressure was 250 psi. Disposal well did not appear to be operating at the time of the inspection. The site was clean and well-maintained. There was no evidence of leaks or excessive corrosion. Perfs (see well schematics): 6556-6586' EL (6552-82' GR) 7/15/75 6610-6630' EL 4/21/98 6648-6680' EL (6644-76' GR) 7/15/75 6680-6695' EL 4/21/98 4spf 6695-6715' EL (6691-6711' GR) 8/06/72
See reverse for additional observations, comments and photo log
Owner/Operator Representative (Optional)
UIC Inspector
Name: Cliff Emmons ___________________________________ Name: Page Cirillo ____________________________________
Signature & Date: see attached field notes ________________ Signature & Date:
10/7/2022 _____________
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 5 9
Year-Month-Day: 2 0 2 2 - 0 9 - 1 3
EPA Permit # (or RA):
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(Cont) ________________________________________________________________________________________________
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Photographer: Jason Rose ____________________________EPA Camera ID: PG camera ID no. 14 S/N:31029537 _______ Photo ID:1________________Time: 10:01 AM ___ Lat (N): NA __________________ Long (W) NA ___________________ Description: Looking south, Black Jack Creek SWDS #1-1 sign alongside access road. ______________________________ Photo ID:2________________Time: 10:04 AM ___ Lat (N): NA __________________ Long (W) NA ___________________ Description: Looking east, site overview, including well head, pressure gauges, valves, and access stairs. ______________ Photo ID:3________________Time: 10:05 AM ___ Lat (N): NA __________________ Long (W) NA ___________________ Description: Looking east, closeup view of surface casing pressure gauge reading 0 psi._____________________________ Photo ID:4________________Time: 10:05 AM ___ Lat (N): NA __________________ Long (W) NA ___________________ Description: Looking east, closeup view of production casing pressure gauge reading 0 psi. __________________________ Photo ID:5________________Time: 10:07 AM ___ Lat (N): NA __________________ Long (W) NA ___________________ Description: Looking southeast, closeup view of internal pressure gauge reading 250 psi. ___________________________
Photo Log
Owner/Operator Representative (Optional)
UIC Inspector
Name: Cliff Emmons ___________________________________ Name: Page Cirillo ____________________________________
Signature & Date: see attached field notes ________________ Signature & Date:
10/7/2022 _____________
Version 2018-04-18
Site Photographs Blackjack Creek SWDS 1-1 #24-1A: September 13, 2022
Photograph 1: Looking south, Blackjack Creek SWDS 1-1 #24-1A sign alongside access road.
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Photograph 2: Looking east, site overview, including well head, pressure gauges, valves, and access stairs. Page 2 of 5
Photograph 3: Looking east, closeup view of surface casing pressure gauge reading 0 psi.
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Photograph 4: Looking east, closeup view of internal pressure gauge reading 0 psi.
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Photograph 5: Looking southeast, closeup view of internal pressure gauge reading 250 psi.
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