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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program EPA Well ID#: I N S P E C T 0 0 1 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 EPA Permit # (or RA): Phone: (404)562-9424 Page 1 Of 2 Inspector(s): ______C__a_r_o__l _C__h_e__n_______________ (lead),______L_o__n_n_i_e__D__o_r_n________________ Start Time: _8_:_5_5___a_m__ ____________________________________, ____________________________________ End Time: _8_:_5_9__a__m__ Facility Contact Information Facility Name:_____L__o_g__s_d_o__n__V__a_l_le__y__O__il__C__o_._,_I_n_c__. _____________________________________________________ Street Address:_____1_0__5__B_e__d_f_o_r_d__C__o__u_r_t________________________________________________________________ City: ____H__o__rs__e__C__a_v_e_______________ County: ________B_a__r_r_e__n________________ State:__K__Y____ Zip: _4_2__7_4__9__ Nature of Business: _____o__i_l_p__r_o__d_u__c_t_i_o_n________________________________________________________________ Facility Owner/Operator: _____M__s__. _E__ll_e_n__S__t_in__s_o__n_,_P__r_e_s__id__e_n__t____________ Phone: ____2__7_0_-_5__3_7__-4__2_8__8_____ Email: ___e__s_t_i_n_s__o_n__@___s__c_r_t_c_._c__o_m_____________________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: ________________________ O/O Mailing Address: _____1_0__5__B__e_d__fo__r_d__C__o_u_r_t___________________________________________________________ City: ____H__o__r_s_e__C__a__v_e______________ County: ______B__a__r_r_e_n__________________ State:__K__Y____ Zip: _4_2__7_4_9___ Well Data from File Well Name & #: ____B_I_L_L__Y__J__O__E__C__A__U_D__E__L__#__U__IC__-_1_____________________________________________________ Well Type (see table): _C__la_s__s_I_I_-_D_,__P_r_o_d__u_c_e__d_W___a_t_e_r__D_i_s_p_o__s_a_l_______ State Permit: _1_1__1_1_4__3__________________ Latitude (N): _____3__7_._1_5__9_7_2__2__________ Longitude (W): _____-_8__5_._7_9__6_2_5_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing Other: __7__"_s_u__rf_a_c__e__c_a_s_i_n_g_,__8__7_/_8_"__h_o_l_e__________________________________ Total Depth (ft): ___3_4_9__'___ Inner Casing Size (in): _4____"___ Tubing Size (in):__2____"____ Packer Depth (ft): _6_5__0____ 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__C__8_2_8__4_ Well Status (see table): __T__A_____ If not Active, Reported Date Last Active: _7__/_3_0__/2__0_1__9______ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ _T_h__e__i_n_j_e_c_t_i_o_n__w__e__ll_i_s__d_i_s_c__o_n_n__e_c__te__d__a_n__d__s_h__o_w__s__s_o__m__e__c_o__r_ro__s_i_o_n__. _N__o__i_n_j_e_c_t_i_o_n__l_in__e__i_s__o_n_s__it_e_._ _T_h__e__s_t_o_r_a_g_e__t_a_n__k_i_s__b_e_s__id__e_t_h_e__i_n_j_e_c_t_i_o_n__w__e_ll__a_n_d__d__o_e_s__n_o__t_h_a__v_e__a_n__y_d__is_p__o_s_a__l _p_i_p_in__g__a_t_ta__c_h_e__d_.___ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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._12_.1_0_1_7:_20_:0_9_-0_5_'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#: I N S P E C T 0 0 1 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ________B__I_L_L__Y__J__O__E___C__A_U__D__E__L___#_U__I_C__-_1_________C__l_a_s__s__I_I-_D__,__P__r_o_d__u_c__e_d___W__a__t_e_r_s__D__i_s_p__o_s__a_l____ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:___C_a__r_o_l_C__h__e_n________________________EPA Camera ID: _S__C__8_2__8_4_____________________________ Photo ID: _D__S_C__N__1_5_1__2_____Time: __8_:_5_5___a_m___ Lat (N): ______0__0_0____________ Long (W) _____0__0_0______________ Description: _i_n__je__c__t_io__n___w__e__ll_________________________________________________________________________ Photo ID: _D__S_C__N__1__5_1__3____Time: __8_:_5_5__a__m___ Lat (N): ______0__0__0___________ Long (W) _____0__0__0_____________ Description: _s__t_o__r_a_g__e___t_a__n_k__________________________________________________________________________ Photo ID: _D__S_C__N__1_5_1__4_____Time: _8_:_5__6__a__m___ Lat (N): ______0__0__0___________ Long (W) ______0_0__0_____________ Description: _s_t_o__r_a_g__e__t_a__n__k___________________________________________________________________________ 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_.1_2_.10_1_7_:2_0:_34_-0_5_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18