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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#: F L S 1 1 3 0 0 5 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 1 2 Page 1 Of 2 Inspector(s): _____C_a__ro_l_C__h_e_n____________________ (lead), _______C_a_r_la__F_o_y_____________________ Start Time: _4_:_1_9__p__m__ ____________________________________ , _______________________________________ End Time: _4_:_2_0__p_m___ Facility Contact Information Well Data from File 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_r_a_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__ St. Regis SWDS #9-2 API No. 09-113-20174 PA No. 311634 Well Name & #: ________________________________________________________________________________________ Well Type (see table): __P__ro__d_u_c_e__d__W__a_t_e_r_D__is_p__o_s_a_l__(P__W__D_)____________ State Permit: _____O_G____9__4_0______________ Latitude (N): ______3__0_._9_6__8_7_2__2_________ Longitude (W): _______-8__7_._1_7__3_9_1__7______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing PBTD: 6546' surface casing 9 5/8" at 2169' Other: __________________________________________________________________ Total Depth (ft): 6__6_0_0__' ____ at 6150' Inner Casing Size (in): 7_"_a_t_2_1__6_9' Tubing Size (in):_4_1__/_2_"____ Packer Depth (ft): __6_1_5__0_'_ Inj. Zone: Open Hole; X Perforated; Top(ft) _6_2__8_5__' _ Bottom(ft): ___6_5_0__0_'___ Max. Injection Pressure (psig): 1_8__0_0__p_s_i Latitude (N): ____3__0_._9_5__8_2__0_5___________ Longitude (W): _____-8__7_._1_6__6_6_4__3________ Elevation (ft): ____________ EPA GPS ID: _S_7_5__3_3_2__ Well Status (see table): _________ If not Active, Reported Date Last Active: __1__0_/_0__3_/_2__0_1__2___ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _I_n_je__c_ti_o_n__w__e_l_l _is__i_n_a_c_t_i_v_e_.____________________________________________________________________________ ___________________________________________________________T_u_b_in__g_g_a__u_g_e_:________0__p__s_i _________________ __________________________________________________________P__ro_d__u_c_t_io_n__g_a_u_g_e__: ____0__p__s_i _________________ __________________________________________________________S__u_r_fa_c_e__g_a_u__g_e_:_______0__p__s_i _________________ __________________________________________________________F__lo_w__l_in_e__g_a_u__g_e_:____________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Field Measurements and Observations 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._07_.0_9_1_0:_46_:5_2_-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 5 3 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 Page 2 0 1 2 Of 2 (Cont) ________________________________________________________________________________________________ ________S_t_._R__e_g_i_s__S_W__D_S__#__9_-_2__________S_t_a_t_e__P_e_r_m__i_t_N__o_._O__G___9__4_0__________A_P__I _N_o__. _0_9__1_1__3_2_0__1_7__4________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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_7__6____Time: ___4_:_2_0__p_m___ Lat (N): ___3__0_._9_5_8__2_0__5_______ Long (W) __-_8_7_._1_6__6_6__4_3_________ Description: __in_j_e_c_t_i_o_n__w_e__ll_a__n_d__id__e_n_t_i_fi_c_a_t_i_o_n__s_ig__n______________________________________________________ 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 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_.0_7_.09_1_0_:4_7:_19_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18