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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 Phone: (404)562-9424 EPA Well ID#: K Y S 1 5 3 0 1 4 1 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 EPA Permit # (or RA): R A Page 1 Of 2 Inspector(s): _C_a__ro__l _C_h_e__n______________________ (lead),___L_o__n_n_i_e__D__o_r_n___________________ Start Time: _9_:_3_0__a__m__ ____________________________________, ____________________________________ End Time: _9_:_3_1__a__m__ Facility Contact Information Facility Name:___S__l_o_n_e__E__n_e_r_g__y_,_L_L__C____________________________________________________________________ Street Address:__8__9_6_6__K__Y__R__T__4_0__W__e__s_t_, _P_._O__._B__o_x__2_2__0__________________________________________________ City: _____Oil Springs _______________ County: _____M_a__g_o_f_fi_n___________________ State:__K__Y____ Zip: __4_1238 Nature of Business: ___o__il_p__r_o_d_u__c_ti_o_n_____________________________________________________________________ Facility Owner/Operator: _____M__r.__S_.__C_h__ri_s__S_l_o_n__e_,_P__E______________________ Phone: _6_0__6_._2_9__7_._5_3__3_0__w__o__r_k__ Email: ________c_h__r_is_s_l_o_n__e_@__s__lo_n__e_e_n__e_r_g_y_._c_o_m___________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: _6_0__6_.2__2_5_._2_2__0_6__c_e__ll_____ O/O Mailing Address: ____________________________________________________________________________________ City: _______________________________ County: _______________________________ State:________ Zip: _________ Well Data from File Well Name & #: ______S_A__L__Y_E__R__S__H__E__I_R__S__#_W___-_3________________________________________________________ Well Type (see table): _C__la_s__s_I_I_-_R_,__E_n__h_a_n__c_e_d__O__il__R_e__c_o_v_e__ry__(_E__O__R_)__ State Permit: __________________________ Latitude (N): _______3_7__.7__0_7_4__3__________ Longitude (W): ______-8__3_._0_1_4__9_5_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing Other: __4_____"__p_r_o__d_u__c_t_io__n__c__a_s__in__g_____________________________________ Total Depth (ft): __________ Inner Casing Size (in): _2______"_ Tubing Size (in):____1_"_____ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _____0_0__0__________________ Longitude (W): ___0__0_0__________________ Elevation (ft): ____________ EPA GPS ID: _S_7__5_3_3__2_ Well Status (see table): ___T__A____ If not Active, Reported Date Last Active: _7_/_0__7_/_2_0__1_0_______ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ _T_h__e__in__je_c__ti_o_n__l_in_e__i_s__d_i_s_c_o_n__n_e_c__te__d__a_n_d__t_h_e__w__e_l_lc_a__p__s_h_o__w_s__c_o__rr_o__s_io__n_.______________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log 8,&,QVSHFWRU UIC Inspector Carol Chen Name:______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C_H__E__N_______D_a_te_: _20_2_4._12_.1_1_1_3:5_1_:0_2_-0_5_'00_' ___ 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#: K Y S 1 5 3 0 1 4 1 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 EPA Permit # (or RA): R A Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _________S__A__L_Y__E__R__S___H__E_I_R__S___#_W___-_3________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_____C__a_r_o_l_C__h_e_n_______________________EPA Camera ID: _S_7__5_3_3_2_______________________________ Photo ID: _R__IM___G__0_1_7__9_____Time: _9_:_3_1___a_m____ Lat (N): ___0__0_0_______________ Long (W) ___0_0_0_________________ Description: _v_i_e_w___o_f__th__e__i_n_j_e_c_t_i_o_n__w__e_l_l_______________________________________________________________ Photo ID: _R__IM__G__0_1__8_0______Time: _9_:_3_1__a__m____ Lat (N): ___0_0__0_______________ Long (W) __0__0_0_________________ Description: _f_a_r_t_h_e__r_b__a_c_k__,_v_i_e_w___o_f__t_h_e__i_n_j_e_c__ti_o_n__w__e__ll________________________________________________ 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: ___________________________________________________________________________________________ 8,&,QVSHFWRU UIC Inspector Carol Chen Name:______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.1_2_.1_1 1_3_:5_1:_26_-_05_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18