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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 Year-Month-Day: 2 0 S 09 23 - 9 00 07 - 0 3 1 8 EPA Permit # (or RA): K Y I 0 3 9 9 Page 1 Of 2 Inspector(s): _______C__a_r_l _E_._W__e__ll_e_r_____________ (lead),_______C_a_r_o__l _C_h_e__n_________________ Start Time: _1_0_:_5_0__a__m_ ____________________________________, ____________________________________ End Time: _1_0_:_5_4__a__m_ Facility Contact Information Logsdon Valley Oil Co., Inc. Facility Name: __________________________________________________________________________________________ Street Address:_____1_0__5__B_e_d__fo__rd__C__o_u_r_t__________________________________________________________________ City: ______H__o_r_s_e__C_a_v_e_______________ County: __________H_a__rt__________________ State:___K__Y___ Zip: __4_2__7_4__9_ Nature of Business: ______O__il_a__n_d__g_a_s__e_x__tr_a_c__ti_o_n__________________________________________________________ Facility Owner/Operator: ____L_o__g_s_d_o_n__V__a_l_le_y__O__il_C__o_._, _In__c_.__________________ Phone: ______2_7_0__-5__3_7__-4__2_8_8_____ Email: ______e_s_t_in__s_o_n_@__s_c_r_t_c_.c__o_m__________S__p_e_n__c_e_r_W___a_lt_e_r_s__s_c_w__1_0__6_@__g_m__a_i_l_.c_o__m_________________________ Facility Contact (if different): _____E_ll_e_n__S__ti_n_s_o__n_,_P__re__s_id__e_n_t____________________ Phone: ______2_7__0_-_5_3__7_-_4_2_8__8____ O/O Mailing Address: _____1_0__5__B_e__d_f_o_r_d__C_o_u__rt_____________________________________________________________ City: _____H__o_r_s_e__C_a_v_e________________ County: __________H_a__r_t_________________ State:___K__Y___ Zip: __4_2__7_4_9__ Well Data from File Lora Turner #5 Well Name & #: ________________________________________________________________________________________ Well Type (see table): _________E_n_h__a_n_c_e__d__O_i_l _R_e__c_o_v_e_r_y__(_E_O_R__)________ State Permit: ________4__6_6_0__5____________ Latitude (N): ________3_7_._1_8__3_8__8_3________ Longitude (W): ______-_8_5__.7__8_3_0__2_4_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: Other: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; erforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _______3__7_._1_8_3__9_6__________ Longitude (W): ______-8__5_._7_8__3_1__6________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ TA Well Status (see table): _________ If not Active, Reported Date Last Active: ____9_/_1__3_/_2__0_1__9___ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ W__h__it_e__b_u_c_k__e_t_p__la_c__e_d__o_v_e_r__th__e__to__p_o__f_t_h_e__w__e_ll_._N__o__g_a_u_g__e_s__a_r_e__p_r_e_s_e_n_t_.________________________________ I_n_j_e_c_t_i_o_n__a_n_d__t_a_n__k__b_a_t_t_e_r_y_l_i_n_e_s__a_r_e__d_i_s_c_o_n_n__e_c_t_e_d__. ___T_u__b_i_n_g__G_a__u_g_e_:___________N_/_A____________________ T__a_n_k__b_a__tt_e_r_y__i_s_c_o__rr_o__d_e_d_.__A__fe__w__f_e_e_t__d_o_w__n_h_i_l_l _o_f______P__r_o_d_u_c__ti_o_n__G__a_u_g__e_:______N_/_A____________________ t_h__e_i_n_j_e_c_t_i_o_n__w_e__ll__is__a_n__u_n__c_o_n_f_i_n_e_d__p_i_t_f_i_ll_e_d__w__it_h_______S_u_r_f_a_c_e__G__a_u_g_e__: _________N_/_A____________________ o__il_y__fl_u_i_d_s_.___________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/OpeUraICtoInr sRpeepcrteosrentative (Optional) UIC Inspector Carl E. Weller Name:_______________________________________________ Name: ________C__a_r_o_l_C__h_e_n____________________________ Signature: _C_A_R__L_W__E_L_L_E__R_(_A_f_fi_li_a_te_)_D_a_te_: 2_02_3._08_.2_9 1_7_:59_:5_7_-0_4'0_0'______ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_3._08_.2_2_1_2:_17_:3_8_-0_4_'0_0'___ 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 EPA Well ID#: K Y S 0 9 9 0 0 0 3 Year-Month-Day: 2 0 2 3 - 0 7 - 1 8 EPA Permit # (or RA): K Y I 0 3 9 9 Phone: (404)562-9424 Page 2 Of 2 (Cont) ____L__o_r_a_T__u_r_n_e_r__#_5_______E_P__A__P_e_r_m__i_t_N__o_._K__Y_I_0_3__9_9______S__ta__t_e_P__e_r_m__i_t_N_o__._4_6__6_0__5_________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_______C_a__rl__E_._W__e__ll_e_r__________________EPA Camera ID: __________S_X_8__1_2__3_____________________ Photo ID: _____2_1_3__________Time: _1__0_:_5_1__a_m___ Lat (N): ______3_7_._1_8__3_9__6______ Long (W) _____-_8_5__.7__8_3__1_6_______ injection well close-up Description: ___________________________________________________________________________________________ Photo ID: _____2_1__4_________Time: 1__0_:5__1_a__m____ Lat (N): ______3_7__.1__8_3_9__5______ Long (W) ______-8__5_._7_8_3__2_0_______ Description: _____________I_n_je__c_t_io_n__w__e_l_l_a_n__d__u_n_c_o__n_f_in__e_d__p_i_t_____________________________________________ 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: ___________________________________________________________________________________________ Owner/OperUaICtoIrnRseppercetoser ntative (Optional) UIC Inspector Name:_____C__a_r_l_E_._W___e_ll_e_r_____________________________ Name: _______C_a_r_o_l__C_h_e__n_____________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3_.08_.2_9_18_:0_0:_47_-0_4_'00_' _____ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_23_.0_8_.22_1_2_:1_8:_04_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18