Document jm6aKELYyJaYy5mkEzoaDYLLk
Inspection ID
Facility Contact Information
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
Inspector(s):
Carl E. Weller
_ (lead), ,
EPA Well ID#: F L S Year-Month-Day: 2 0 2
EPA Permit # (or RA):
1 1 3 -
F L
Page
3 0 0 3
I 0
1
05 9
-2 8 0 0 3
Of 2
Carol Chen
Start Time: 11:05 am
End Time: 11:13 am
Facility Name: Street Address: City:
Black Creek Energy, LLC
4940 Blackjack Plant Rd.
Jay
County:
Santa Rosa
Nature of Business:
Oil and gas production
Facility Owner/Operator:
Black Creek Energy, LLC
Email:
Mike Wetzel <mikew2859@gmail.com>
Facility Contact (if different):
Michael Wetzel
O/O Mailing Address: 140 Virginia Street, Suite 302
City:
Richmond
County:
N/A
State: FL
Zip:32565-9260
Phone: 601-431-5386 Phone: 850-324-6271
State: VA Zip: 23219
Well Name & #: Black Jack Creek (BJC) SWDS 1-1 #24-1A
API No. 0911320060 PA No. 302387
Well Type (see table):
Produced Water Disposal (PWD)
State Permit:
OG_ 555A
Latitude (N):
30.84680088
Longitude (W):
-87.09418218
Elevation (ft):
Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing
PBTD: 7400'
Other: srfc csg 10" @ 4250'
Otis WB packer
Total Depth (ft): 7480' Inner Casing Size (in):
Tubing Size (in):
Packer Depth (ft): 5695'
Inj. Zone: Open Hole; X Perforated; Top(ft) 6556' Bottom(ft): 6715' Max. Injection Pressure (psig): 1800 psi
Latitude (N):
30.84685
Longitude (W):
-87.09422
Elevation (ft):
EPA GPS ID: SX8123 Well Status (see table): AC If not Active, Reported Date Last Active:
Nature of Injected Fluid(s) if any:
Produced fluids
General Condition of the Well Site:
Well Data from File
Field Measurements and Observations
Notes & Comments (include discrepancies from database values): This well is planned for plugging and abandonment.
Tubing gauge: Production gauge: Surface gauge:
290 psi 0 psi 0 psi
Injection well passed a mechanical integrity test on 8/24/2022
See reverse for additional observations, comments and photo log
UIC Inspector
UIC Inspector
Name: Signature:
Carl E. Weller
Digitally signed by CARL WELLER
CARL WELLER (Affiliate) (Affiliate)
Date: 2023.05.11 13:38:05 -04'00'
Name: Carol Chen
CAROL CHEN Date: 2023.05.10 19:54:17 -04'00' Digitally signed by CAROL CHEN
Signature:
Version 2018-04-18
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
(Cont)
EPA Well ID#: F L S 1 1 3 0 0 5 9 Year-Month-Day: 2 0 2 3 - 0 3 - 2 8
EPA Permit # (or RA): F L I 0 0 0 3
Page 2 Of 2
Field Measurements and Observations (Cont.)
Photo Log
Photographer: Photo ID: Description: Photo ID: Description:
Carl E. Weller
145
Time: 11:00 am
146
Time: 11:08 am
EPA Camera ID:
SX8123
Lat (N): 30.84718
Long (W) -87.09395
sign posted (both signs shown for OG_555A and OG_555B)
Lat (N): 30.84685 photo of injection well
Long (W) -87.09422
Photo ID:
Time:
Lat (N):
Long (W)
Description:
Photo ID:
Time:
Lat (N):
Long (W)
Description:
Photo ID:
Time:
Lat (N):
Long (W)
Description:
Photo ID:
Time:
Lat (N):
Long (W)
Description:
UIC Inspector
Name: Signature:
Carl E. Weller
CARL WELLER (Affiliate)
Digitally signed by CARL WELLER (Affiliate) Date: 2023.05.11 13:38:40 -04'00'
UIC Inspector
Name: Carol Chen
CAROL CHEN Digitally signed by CAROL CHEN Date: 2023.05.10 19:54:48 -04'00'
Signature:
Version 2018-04-18