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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#: K Y S 1 5 3 0 1 6 8 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 EPA Permit # (or RA): R A Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _C_a__ro__l _C_h_e__n______________________ (lead),_____L_o__n_n_ie__D__o_r_n__________________ Start Time: _9_:_3_5___a_m__ ____________________________________, ____________________________________ End Time: _9_:_3_6__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_f_in__________________ State:__K_Y_____ Zip: _41238 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__ri_s_s_lo__n_e_@__s_l_o_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 & #: ______R__.__L_._S__A__L_Y__E__R__S__-__J_I_M___A_R__N__E__T_T___#_W___-2_________________________________________ 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__6_4_3___________ Longitude (W): _____-8__3_._0_1_5__7_2__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing Other: __4____"__p__r_o_d__u_c__ti_o__n__c_a__s_i_n_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__i_n_j_e_c_t_i_o_n__li_n_e__f_r_o_m___th__e__ta__n_k__b_a_t_t_e_r_y__is__n_o__t_c_o__n_n_e__c_te__d__to__t_h_e__i_n_j_e_c_t_io__n__w_e__ll_._T__h_is__w__e_l_l_i_s_i_n_a__c_ti_v_e. _T__h_e__w__e_l_lc_a__p__s_h_o_w__s__c_o_r_r_o_s__io_n__._____________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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._12_.1_1_1_1:_15_:5_6_-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#: K Y S 1 5 3 0 1 6 8 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 EPA Permit # (or RA): R A Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______R__.__L_.__S__A__L_Y__E__R__S__-__J__IM___A__R__N__E__T__T__#__W__-_2__________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:___C_a__r_o_l_C__h__e_n________________________EPA Camera ID: ____S_7__5_3__3_2___________________________ Photo ID: __R__I_M__G__0_1__8_1____Time: _9_:_3_6___a_m____ Lat (N): ____0_0__0______________ Long (W) __0__0_0_________________ Description: ___v_ie__w__o__f_t_h_e___in__je__c_t_io__n__w__e_l_l _____________________________________________________________ Photo ID: __R__I_M__G_0__1_8_2_____Time: _9_:_3_6__a__m____ Lat (N): ____0__0_0______________ Long (W) ___0_0_0_________________ Description: __c__lo__s_e_-_u__p__o_f__th__e__i_n_j_e_c_t_i_o_n__w__e_l_l_________________________________________________________ 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 Carol Chen Name:______________________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.1_2_.11_1_1_:1_6:_23_-_05_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18