Document p2p394xR1den6JVQN4XdxGLbD
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
Inspector(s):
Carol Chen
_ (lead), ,
EPA Well ID#: F L S 1 1 3 0 0 5 9 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1
EPA Permit # (or RA): F L I 0 0 0 3
Page 1 Of 2
Carla Foy
Start Time: 2:10 pm End Time: 2:12 pm
Facility Contact Information
Facility Name: Street Address: City:
Black Creek Energy, LLC
4940 Blackjack Plant Rd.
Jay
County:
Santa Rosa
Nature of Business:
Oil and gas production
Facility Owner/Operator: Email:
Harris D. Butler, III harris.butler@butlerroyals.com
State: FL
Zip:32565-9260
Phone: (804)-334-0527
Facility Contact (if different):
O/O Mailing Address: 140 Virginia Street, Suite 302
City:
Richmond
County:
N/A
Phone:
State: VA
Zip: 23219
Well Data from File
Well Name & #: Black Jack Creek (BJC) SWDS 1-1 #24-1A API No. 0911320060 PA No. 302387
Well Type (see table):
Produced Water Disposal (PWD)
State Permit:
OG_555
Latitude (N):
30.84680088
Longitude (W):
-87.09418218
Elevation (ft):
Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing
PBTD: 7400'
Other: srfc csg 10" @ 4250'
Otis WB packer
Total Depth (ft): 7480' Inner Casing Size (in):
Tubing Size (in):
Packer Depth (ft): 5695'
Inj. Zone: Open Hole; X Perforated; Top(ft) 6556' Bottom(ft): 6715' Max. Injection Pressure (psig):1800 psi
Latitude (N):
No GPS 000
Longitude (W):
No GPS 000
Elevation (ft):
EPA GPS ID: SX8123 Well Status (see table): PA If not Active, Reported Date Last Active:
Nature of Injected Fluid(s) if any:
General Condition of the Well Site:
Field Measurements and Observations
Notes & Comments (include discrepancies from database values):
This well was plugged on 4/21/24 and is gone now.
Tubing gauge: Production gauge: Surface gauge:
Name:
See reverse for additional observations, comments and photo log
U IC Inspector
UIC Inspector
Carol Chen
Name:
Signature: CAROL CHEN
Digitally signed by CAROL CHEN Date: 2024.06.24 11:12:10 -04'00'
Signature:
UIC Inspector:
UIC Inspector:
Version 2018-04-18
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#: F L S 1 1 3 0 0 5 9 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1
EPA Permit # (or RA): F L I 0 0 0 3 Page 2 Of 2
(Cont)
Black Jack Creek (BJC) SWDS 1-1 #24-1A
Field Measurements and Observations (Cont.)
Photo Log
Photographer:
Carol Chen
Photo ID: DSCN1455 Time:
2:12 pm
EPA Camera ID:
Lat (N): No GPS 000
SC8284
Long (W)
Description: only dirt on the property, injection well is plugged Photo ID: DSCN1456 Time: 2:13 pm Lat (N): No GPS 000
Long (W)
Description: closer to the area where the injection well was before, now gone
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:
Name:
U IC Inspector)
Carol. Chen
Name:
UIC Inspector
Signature: CAROL CHEN
Digitally signed by CAROL CHEN Date: 2024.06.24 11:12:33 -04'00'
Signature:
No GPS 000 No GPS 000
Version 2018-04-18
UIC Inspector:
UIC Inspector: