Document ndRmX8O4VYe9g4xLyq4yamx6

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 1 1 3 0 0 4 2 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 0 8 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: _2_:_2_5__p_m___ ____________________________________, ______________________________________ End Time: _2_:_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________________________________________________________ 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 Field Measurements and Observations Well Name & #: ____S_t_._R_e__g_is__S__W_D__S__#_1__-2_______________________A_P__I _N_o__. _0_9__-1__1_3__-2__0_1_4__5____P__A_N__o_.__3_1_1__6_0__1_ Well Type (see table): __P__ro__d_u_c_e__d__W_a__te__r_D__is_p__o_s_a_l_(_P__W_D__)____________ State Permit: _______O_G____8__0_8____________ Latitude (N): ________3_0_.9__6_3_4_8_9__________ Longitude (W): _____-8_7_._1_8_2_9__6_7__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD:6573' Other: __s_u_r_f_a_c_e__c_a_s_i_n_g__9__5_/_8__"_a_t_2__1_6__6_'__________________________________ at 6300' Total Depth (ft): __6_6_0__0_'___ Inner Casing Size (in):7_"_a_t_6_5__9_9' Tubing Size (in):_3__1__/_2_"___ Packer Depth (ft): _6__2_4__3_'_ Inj. Zone: Open Hole; X Perforated; Top(ft) _6_4_8__0_'__ Bottom(ft): __6__5_4_0__' ___ Max. Injection Pressure (psig): 1_7__7_9__p_s_i Latitude (N): ______3_0__.9__6_3__5_5_1__________ Longitude (W): _____-_8_7_._1_8__2_9__5_3________ Elevation (ft): ____________ S75332 AC EPA GPS ID: _________ Well Status (see table): _________ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: ______P_r_o_d_u__c_e_d__W__a_t_e_r_s__(_P_W__)______________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _S_i_g_n__is__p_o__s_te__d__s_h_o_w__in__g_w__e_l_l _id__e_n_t_if_i_c_a_t_io__n_.___________________________________________________________ _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__f_lu__id__s_. __________________T_u__b_in_g__g_a_u__g_e_: ________9_5__0__p_s_i_____________ ____________________________________________________________P__ro_d__u_c_t_io_n__g_a_u_g_e__: ____5_0___p_s_i______________ ____________________________________________________________S__u_rf_a_c_e__g_a_u_g__e_: _______0__p_s__i _______________ ____________________________________________________________F_l_o_w__l_in_e__g_a_u_g__e_: __________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log 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_2_1:_33_:5_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 1 1 3 0 0 4 2 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 0 8 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______S_t_._R__e_g_i_s_S__W__D_S__#_1__-_2___________S_t_a_t_e__P_e_r_m__i_t _N_o__._O_G____8__0_8____________A_P_I__N_o_.__0_9_1__1_3__2_0_1__4_5________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen S75332 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: __R__IM__G_0__1_4_6______Time: __2_:_2_9__p_m____ Lat (N): ____3_0_._9_6_3__5_5_1________ Long (W) ____-_8_7_._1_8_2__9_5_3________ Description: ___in__je_c__ti_o_n__t_u_b_i_n_g__g_a_u__g_e__r_e_a_d_s__9_5__0__p_s_i____________________________________________________ Photo ID: __R__IM__G_0__1_4_7______Time: ___2_:3__0_p_m____ Lat (N): ____3_0_._9_6_3__5_5_1________ Long (W) ____-_8_7_._1_8_2__9_1_8________ Description: ___p_r_o_d_u__c_t_io_n__g_a__u_g_e__r_e_a_d__s_5__0__p_s_i__________________________________________________________ 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 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_: 2_0_24_.0_6_.20_2_1_:3_4:_21_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18