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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 EPA Well ID#: K Y S 1 5 3 0 1 4 6 Year-Month-Day: 2 0 2 4 - 1 0 - 2 2 EPA Permit # (or RA): R A Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _C__a_r_o_l__C__h_e__n____________________ (lead),_______L_o__n_n__ie__D__o__r_n______________ Start Time:1_1_:_1__4__a_m__ ____________________________________, ____________________________________ End Time1: _1_:_1__5__a_m__ Facility Contact Information Facility Name:______S__lo__n_e__E__n_e__r_g_y_,__L_L__C________________________________________________________________ Street Address:___8__9_6__6__K_Y___R__T__4__0__W__e__s_t_, _P__.O__.__B__o_x__2_2__0______________________________________________ City: __O__il_S__p__ri_n_g__s__________________ County: ____M___a_g_o__f_fi_n__________________ State:__K__Y____ Zip: _4__1_2__3_8__ Nature of Business: ____o__il__p_r_o__d__u_c__t_io__n_________________________________________________________________ Facility Owner/Operator: _____M__r_.__S_.__C__h_r_is__S__a__lo__n_e_,__P__E__________________ Phone: _6_0__6_._2_9__7_._5_3__3_0__w__o__r_k__ Email: ___________c_h_r_i_s_s_l_o_n__e_@___s_l_o_n_e__e_n__e_r_g_y__._c_o_m______________________________________________________ Facility Contact (if different): ________________________________________________ Phone: _6_0__6_._2_2__5_._2_2__0_6__c__e_l_l ___ O/O Mailing Address: ____________________________________________________________________________________ City: _______________________________ County: _______________________________ State:________ Zip: _________ Well Data from File Well Name & #: __J_._P__.__C_O__N__L__E_Y___#_W___-_5________________________________________________________________ Well Type (see table): _C__la_s__s_I_I_-_R_,__E_n__h_a_n__c_e_d__O__il__R_e__c_o_v_e__ry__(_E__O__R_)__ State Permit: __________________________ Latitude (N): ______3_7__.7__7_8__7_5___________ Longitude (W): _____-8__3_._0_0__9_9__4_________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing Other: _4____"__p_r_o__d_u__c_t_io__n__c_a__s_in__g________________________________________ Total Depth (ft): __________ Inner Casing Size (in): _2______"_ Tubing Size (in):____1_"_____ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): ____3__7_._7_7__8_3__7____________ Longitude (W): ___-_8_3__.0__1_0__3_9___________ Elevation (ft): ____________ EPA GPS ID: S__7_5__3_3__2_ Well Status (see table): __A__C_____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: _P__ro__d_u__c_e__d__W__a__te__r_s__(P__W___)_______________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _____________________________________________________________________________________________________ _T_h__e__i_n_j_e_c_t_i_o_n__l_in__e__i_s__c_o_n__n_e__c_t_e_d_,__f_e_e_l_s__i_c_y__c_o__ld__._P__r_o_d__u_c_e__d__w__a_t_e_r_s__a__re___b_e_i_n_g___in__je__c_t_e_d__f_o_r_____ _e_n__h_a_n__c_e_d__o_i_l _r_e_c_o__v_e_r_y_.__G_a__u_g_e__s__w_e__re__n__o_t_f_o_u__n_d__t_o__m__o_n_i_to__r_i_n_j_e_c_t_io__n__a_n_d__a__n_n_u__lu_s__p__re__s_s_u_r_e_s__. _____ _W__e_l_l_c_a_p__s_h__o_w__s_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_8:_09_: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 1 5 3 0 1 Year-Month-Day: 2 0 2 4 - 1 0 - EPA Permit # (or RA): R A Page 2 Of 46 22 2 (Cont) ________________________________________________________________________________________________ _________J__._P__.__C__O__N__L__E__Y___#__W__-_5___________C__l_a_s__s__I_I-_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__7_5_3__3_2______________________________ Photo ID: _R__IM__G__0_1__9_0______Time: _1_1__:_1_4___a_m__ Lat (N): ___3__7__.7__7_8__3_7________ Long (W) ___-_8__3_._0_1__0_3__9________ Description: _i_n__je__c__ti_o__n__w__e__l_l_________________________________________________________________________ Photo ID: _R_I_M__G__0_1_9_1_______Time: _1_1__:1__4__a__m__ Lat (N): ___3__7_._7_7__8_8__7_8_______ Long (W) ___-_8__3_._0_1__0_4__8_3_______ Description: _i_n_j_e__c_t_i_o_n___w__e__ll_,__d_i_f_f_e_r_e__n__t_a__n__g_l_e______________________________________________________ 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_.1_2_.10_1_8_:0_9:_55_-0_5_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18