Document rx66NOXo4Lp4Qzy5y6yQ7bzV0
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 0 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1
EPA Permit # (or RA):
Carla Foy
Page 1 Of 2
Start Time: 1:50 pm End Time: 1:59 pm
Facility Contact Information
Facility Name: Street Address: City:
Black Creek Energy, LLC
4940 Blackjack Plant Rd.
Jay
County:
Nature of Business:
Oil and gas production
Facility Owner/Operator:
Harris D. Butler, III
Email:
harris.butler@butlerroyals.com
Santa Rosa
Facility Contact (if different):
O/O Mailing Address: 140 Virginia Street, Suite 302
City:
Richmond
County:
N/A
State: FL
Zip:32565-9260
Phone: (804)-334-0527
Phone:
State: VA
Zip: 23219
Well Data from File
Well Name & #: Albert L. Rosasco #19-4
Well Type (see table): Enhanced Oil Recovery (EOR)
Latitude (N):
30.8379534
Longitude (W):
API No. 0911320068 PA No. 303046
State Permit:
-87.07942527
OG_ 578
Elevation (ft):
Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing
PBTD: 16148'
Other: srfc csg
Total Depth (ft): 16250' Inner Casing Size (in):
Tubing Size (in):
Packer Depth (ft): 15275'
Inj. Zone: Open Hole; X Perforated; Top(ft) 15828' Bottom(ft): 15877' Max. Injection Pressure (psig): 2500 psi
Latitude (N): No GPS 000
Longitude (W): No GPS 000
Elevation (ft):
EPA GPS ID: SX8123 Well Status (see table): SI
If not Active, Reported Date Last Active: 9/13/22
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 is inactive, shut-in. The injection lines are physically disconnected from the injection well.
Tubing gauge:
0 psi
Production gauge: 0 psi
Surface gauge:
0 psi
See reverse for additional observations, comments and photo log
U IC Inspector
UIC Inspector
Name: Carol Chen
Name:
Signature: CAROL CHEN
Digitally signed by CAROL CHEN Date: 2024.06.24 10:37:14 -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
(Cont)
Albert L. Rosasco #19-4
EPA Well ID#: F L S 1 1 3 0 0 0 5 Year-Month-Day: 2 0 2 4 - 0 5 - 0 1
EPA Permit # (or RA):
Page 2 Of 2
Field Measurements and Observations (Cont.)
Photo Log
Photographer:
Carol Chen
Photo ID: DSCN1446 Time:
1:52 pm
EPA Camera ID:
Lat (N): No GPS 000
Description: well identification sign at property entrance
Photo ID: DSCN1447 Time: 1:53 pm Lat (N): No GPS 000
Description: injection well, tubing gauge reads 0 psi Photo ID: DSCN1448 Time: 1:53 pm Lat (N):
No GPS 000
Description: 2nd photo injection well
Photo ID: DSCN1449 Time: 1:54 pm Lat (N): No GPS 000
Description: production and surface gauges read 0 psi
Photo ID:
Time:
Lat (N):
Description:
Photo ID:
Time:
Lat (N):
Description:
U IC Inspector)
Name:
Carol Chen
Name:
Signature: CAROL CHEN
Digitally signed by CAROL CHEN Date: 2024.06.24 10:37:44 -04'00'
Signature:
SC8284
Long (W)
No GPS 000
Long (W) No GPS 000
Long (W) No GPS 000
Long (W)
No GPS 000
Long (W)
Long (W)
UIC Inspector
Version 2018-04-18
UIC Inspector:
UIC Inspector: