Document pmVgbYj5MxGzejYdjJEOv4gb6

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 0 9 9 0 0 0 3 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 EPA Permit # (or RA): K Y I 0 3 9 9 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): __C__a_r_o__l _C__h_e__n___________________ (lead),_____L_o__n_n_i_e__D_o__r_n_________________ Start Time: _7_:_3_5___a_m__ ____________________________________, ____________________________________ End Time: _7_:_4_0__a__m__ Facility Contact Information Facility Name:_____L_o_g__s_d_o__n__V_a__ll_e_y__O__il_C__o_._,_I_n_c__. ________________________________________________________ Street 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__ Nature of Business: _______o_i_l_p__r_o_d_u__c_t_io__n________________________________________________________________ Facility Owner/Operator: _____M__s_.__E_l_le__n__S__ti_n_s__o_n__,_P__r_e_s_i_d_e__n_t_____________ 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______________________________________________________________________ Facility Contact (if different): ________________________________________________ Phone: ________________________ O/O Mailing Address: _____1__0_5__B__e_d__fo__r_d__C__o_u__rt___________________________________________________________ City: ____H__o_r_s__e__C__a_v_e_______________ County: ________H__a__rt___________________ State:_K_Y______ Zip: _4_2__7_4_9___ Well Data from File Well Name & #: ______L__O__R_A___T_U__R__N__E__R__#__5_____________________________________________________________ Well Type (see table): _C__la__s_s__II_-_R__, _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_9__4_7___________ Longitude (W): ____-_8_5_._7_8_3_1__3_2__________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; XTubing & Packer; Cemented Injection Tubing Other: ___s_u_r_f_a__c_e__6____"__________________________________________________ Total Depth (ft): __6_3__8_____ Inner Casing Size (in): __4____"__ Tubing Size (in):__2_____"___ Packer Depth (ft): _5__9__7___ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Latitude (N): ______0_0__0_________________ Longitude (W): _____0__0__0_______________ Elevation (ft): ____________ EPA GPS ID: S__C__8__2_8__4 Well Status (see table): __A___C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _____P_r_o_d__u_c_e__d__W__a_t_e_r_s__(_P_W__)______________________________________________ Field Measurements and Observations General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ _C__a_n__h__e_a__r_t_h_e__t_r_i_c_k_l_in__g__s_o__u_n_d__s__o_f__p_r_o__d_u_c__e_d__w__a__te__r_s_,_f_l_o_w__in__g__u_n__d_e__r_g__r_a_v_i_t_y__p_r_e_s__s_u_r_e__,________ _f_o_r_e__n_h_a__n_c_e_d__o__il__re__c_o_v_e__ry__. _T_h__e__a_n_n__u_l_u_s__p_r_e_s_s__u_r_e__g_a_u__g_e__is__d__a_m__a_g__e_d_/_il_le__g_i_b_l_e_._T__h_e__f_le_x__ib_l_e________ _g_r_e__e_n__li_n_e__f_r_o_m___th__e__ta__n_k__b_a_t_t_e_r_y__c_a_r_r_ie__s__p_r_o_d_u__c_e_d__w__a_t_e_r_s__to__t_h_e__w__h_i_t_e__p_la__s_t_ic__t_u_b_i_n_g__f_o_r__in_j_e_c__ti_o_n_._ _T_h__e__m__e__ta__ll_i_c__p_a_r_t_s__o_f__t_h_e__w__e_l_l_c_a_p__s__h_o__w__c_o__r_r_o_s_i_o_n__._____________________________________________ _____________________________________________________________________________________________________ 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._12_.1_0_1_7:_23_:3_2_-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 0 9 9 0 0 0 3 Year-Month-Day: 2 0 2 4 - 1 0 - 2 4 EPA Permit # (or RA): K Y I 0 3 9 9 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _________L_O__R__A___T__U__R__N__E__R__#__5__________C__la__s_s___II_-_R__,__E_n__h__a_n__c_e__d__O__i_l _R__e__c_o__v_e_r_y___(E__O__R__)__________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:__C__a_r_o__l _C__h_e__n________________________EPA Camera ID: _S__C__8_2__8_4_____________________________ Photo ID: _D__S_C__N__1_4_9__5_____Time: _7_:_3_5__a__m____ Lat (N): _____0_0__0_____________ Long (W) _____0_0__0______________ Description: _in__je__c_t_i_o_n___w__e_l_l_a__n_d___o_n__e__s_t_o__r_a_g__e__t_a_n__k__i_s__v_i_s_i_b_l_e______________________________________ Photo ID: _D__S_C__N__1__4_9__6____Time: _7_:_3_5___a_m____ Lat (N): _____0_0__0_____________ Long (W) _____0__0_0______________ Description: _i_n__je__c__ti_o__n__w__e__l_l_a__n_d___g__r_o_u__p__o__f__t_a_n__k_s___a_r_e___v_i_s_i_b__le___________________________________ Photo ID: _D__S_C__N__1_4_9__7_____Time: _7_:_3_7__a__m____ Lat (N): _____0_0__0_____________ Long (W) _____0__0__0_____________ Description: _p_r_o__d_u__c__ti_o__n__w__e__l_l_i_s__n__e_a__r_b__y___________________________________________________________ Photo ID: _D__S_C__N__1__4_9__8____Time: _7_:_3_7___a_m____ Lat (N): _____0__0_0_____________ Long (W) _____0__0_0______________ Description: _g_a__u_g__e___o_n___t_h_e___p_r_o__d__u_c__e_r______________________________________________________________ Photo ID: _D__S_C__N__1_4_9__9_____Time: _7_:_3_8__a__m____ Lat (N): _____0_0__0_____________ Long (W) _____0__0__0_____________ Description: b__a_c__k_s__id__e__o__f_t_h_e___p_r_o__d_u__c_e__r_____________________________________________________________ Photo ID: _D__S_C__N__1__5_0__0____Time: _7_:_3_8___a_m____ Lat (N): _____0__0_0_____________ Long (W) _____0__0_0______________ Description: c__lo__s_e__-_u__p__o__f_t_h__e__p__r_e__s_s__u_r_e___g_a__u__g_e____________________________________________________ UIC Inspector UIC Inspector Name:______________________________________________ Name: ____Carol Chen______________________________ Signature: ___________________________________________ CAROL CHEN Digitally signed by CAROL CHEN Date: 2024.12.10 17:24:00 -05'00' Signature: ___________________________________________ Version 2018-04-18