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Inspection ID Facility Contact Information Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program EPA Well ID#: F L S 1 1 3 0 0 2 2 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 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), _______C_a_r_l_a_F_o__y____________________ Start Time: __2_:_4_3__p_m__ ____________________________________ , _______________________________________ End Time: _2_:_4_4__p__m__ 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_i_tb__u_r_n__O_p_e__ra__t_in_g__, _L_P_)______________________ 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 Name & #: _____J_. _F_._S__H_E_L__L_#__2_0__-1___________________A__P_I_N__o_._0__9_1_1__3_2__0_0_1__9____P_A__N_o__._3_1__1_5_7__9_________ Well Type (see table): __E__n_h_a__n_c_e_d__O__il_R__e_c_o__v_e_r_y_(_E_O__R_)_______________ State Permit: ____O__G____4_8_3_______________ Latitude (N): _______3_0__.9__5_1_8__8_2_________ Longitude (W): ______-_8_7__.1__7_5_4__0_8_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15902' Other: __s_u_rf_a_c_e__c_a_s_in_g__1_0_3__/_4_"_a_t_3_7_4__8_' _____________________________________ Total Depth (ft): 1_5__9_9__3_'___ Inner Casing Size (in):7_"_1__5_9_9__3 Tubing Size (in):3__1_/_2_"_1_5__4_80'Packer Depth (ft): _1_5__3_5__4_' Inj. Zone: Open Hole; X Perforated; Top(ft) _1_5__6_0_0__' Bottom(ft): __1_5__7_5_0__' __ 7500 N2 gas Max. Injection Pressure (psig):44__0_0_p_s_i_P_W Well Data from File Field Measurements and Observations Latitude (N): __________________________ Longitude (W): ________________________ Elevation (ft): ____________ EPA GPS ID: _________ Well Status (see table): ___P__A____ If not Active, Reported Date Last Active: __________________ 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_s_p_e_c__to__rs__w__e_r_e__in_f_o_r_m__e_d__t_h_i_s__w_e__ll_w__a_s__p_l_u_g_g_e__d_,_b_u__t____________________________________________ _w_e__d_i_d__n_o_t__s_t_o_p__t_o_s_e__e__th__e_l_e_a__s_e__a_t_t_h_a_t__t_im__e_,__ju_s_t__d_r_o_v_e_______T_u_b_i_n_g__g_a_u_g_e_:___________________________ _p_a__s_t_t_h_e__g_e_n__e_r_a_l_a__re__a_._______________________________________P_r_o_d_u_c_t_io_n__g_a_u__g_e_:_______________________ Surface gauge: _____________________________________________________________________________________________________ ______________________________________________________________F_l_o_w__li_n_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:_26_:5_5_-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 2 2 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _______J_._F_.__S_h_e_l_l_#__2_0_-_1________S__ta__te__P__e_r_m__it__N_o_.__O_G____4_8__3_______A_P__I _N_o__. _0_9__1_1_3__2_0__0_1_9___________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _N__o__p_h_o_t_o_s__t_a_k_e__n____________________________________________________________________________________ Photo Log Photographer:____C__a_r_o_l_C_h__e_n________________________EPA Camera ID: _______S_7_5__3_3__2________________________ Photo ID: _N__o_p_h__o_to__s_t_a_k_e_n__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: ___________________________________________________________________________________________ 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_.0_6_.20_2_1_:2_7:_22_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18