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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 0 3 3 0 0 0 5 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 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: _1_0_:_0_0__a__m__ ___________________________________ , _______________________________________ End Time: 1__0_:_1_3__a_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_it_b_u__r_n_O__p_e__ra__ti_n_g_,__L_P_)_______________________ Street Address:_5__4_1__5__O_i_l _P_l_a_n_t__R_d_______________________________________________________________________ City: _____J_a_y________________________ County: ___E__s_c_a_m__b_i_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: ____E__s_c_a_m__b_i_a__________________ State:__F_L_____ Zip: __3_2__5_6_5__ Well Data from File Well Name & #: __M__c_D__a_v_i_d__L_a_n_d__s_#__3_7__-1____________A__P_I_N__o_._0__9_0_3__3_2__0_0_0__4___________P_A__N_o__. _3_1__1_5_7__6_______ 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___4__6_3_______________ Latitude (N): _______3_0_._9__9_4_1__1_2_________ Longitude (W): _______-8__7_._1_9_2__7_4________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15,532' 6 sets of perfs smackover Other: __s_u_r_f_a_c_e__c_a__s_in__g_1__0__3_/_4__"_t_o__3_,_5_0__0_'_______________________________ Total Depth (ft): 1__5_,_6_5__3_'__ Inner Casing Size (in): _8__1__/_2_"_ Tubing Size (in):_2__7__/_8_"___ Packer Depth (ft): _1_5__,1__5_0_' Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5_,_2_8_4_'_ Bottom(ft): _1_5_,_3_8_4_'____ 7,500 psi N2 4,400psi PW Max. Injection Pressure (psig): ________ 30.994065 -87.192707 Latitude (N): __________________________ Longitude (W): ________________________ 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_r_o_d__u_c_e_d__W__a__te__rs__(_P_W__)_______________________________________________ Field Measurements and Observations General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ T_h_e____"__T_-_s_k__il_le__t _w__a_s_i_n__p_l_a_c_e__t_o__h_a_l_t_i_n_j_e_c_t_io_n__f_r_o_m___th__e__n_it_r_o_g_e__n____T_u_b_i_n_g_g_a_u_g_e_:_______2__6_0__0__p_s_i_______ (N) flowline. The nitrogen manifold was also disconnected. Production gauge: 0 psi _____________________________________________________________________________________________________ T_h_i_s__w_e__ll_i_s__a_c_t_iv_e__ly__in__je_c__ti_n_g__p_r_o_d__u_c_e_d__w__a_t_e_r_s__fo__r_e_n_h__a_n_c_e__d________S__u_rf_a_c_e_g_a_u__g_e_: _____0__p__s_i ___________ o_i_l_r_e_c_o__v_e_r_y_.________________________________________________________F_lo_w__li_n_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:_21_:0_3_-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 0 3 3 0 0 0 5 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______M__c_D__a_v_i_d__L_a_n_d__s_#__3_7__-1__________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _P_h_o_t_o__ID__: _R__IM__G__0_1__0_3____T_i_m__e_: _1__0_:_1_3__a_m_____L__a_t_(__N_)_:_3_0_._9_9__4_3_9_8__6__________L_o_n_g__(__W_)_:__-8__7_.1__9_2_8__5_6_______ Description: _____________________________________________________________________________________________________ Photo Log Carol Chen S75332 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: ____R_I_M__G_0__0_9_7____Time: __1_0_:_0_0__a_m___ Lat (N): __N_o__G_P__S_U__n_i_ts__0_0_0____ Long (W) __N__o_G__P_S__U_n_i_ts__0_0__0____ sign showing identification of the injection well Description: ___________________________________________________________________________________________ Photo ID: ____R_I_M__G__0_0_9__8___Time: _1__0_:_0_5__a_m___ Lat (N): __3__0_.9__9_4_0__9_7_________ Long (W) __-_8_7__.1_9__2_7_6___________ annulus gauge Description: ___________________________________________________________________________________________ Photo ID: ____R__IM__G__0_0__9_9___Time: _1_0__:0_9__a__m___ Lat (N): __3_0__.9_9__4_0_6__5_________ Long (W) __-_8_7__.1_9__2_7_1__7_________ " T-skillet prevents injection from the nitrogen (N) flowline Description: ___________________________________________________________________________________________ Photo ID: ____R__IM__G__0_1__0_0___Time: _1_0_:1_0__a_m_____ Lat (N): __3_0_._9_9__4_0_6_5__________ Long (W) ___-8__7_.1__9_2_7__0_7_________ Description: ______c_l_o_s_e_-u__p_p__f ___"_T_-_s_k_il_le__t,_w__h_i_c_h_h__a_lt_s_t_h_e__N___f_lo_w__li_n_e_______________________________________ Photo ID: ____R__IM__G__0_1__0_1___Time: _1_0_:_1_1_a_m_____ Lat (N): __3_0__.9_9__4_0_6__6_________ Long (W) ___-8_7__.1__9_2_8_6___________ device: flowline analyzer Description: ___________________________________________________________________________________________ Photo ID: ____R__IM__G__0_1__0_2___Time: _1_0__:1_2__a__m___ Lat (N): ___3_0_._9_9_4__1_4_8_________ Long (W) ___-8_7__.1__9_2_8_5__6_________ Description: ______v_ie__w__o_f_t_h_e__in_j_e_c_t_io_n__w__e_ll_, _fa__rt_h_e_r__a_w_a__y__________________________________________________ UIC Inspector UIC Inspector Name:_______C_a_r_o_l_C_h_e__n_______________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C_H__E__N_______D_a_te_: _20_2_4._06_.2_0_21_:2_1_:2_9_-0_4'_00_' ___ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18