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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 0 Year-Month-Day: 2 0 2 3 EPA Permit # (or RA): K 9 90 -0 7 Y I 0 0 1 2 - 18 6 63 Phone: (404)562-9424 Page 1 Of 2 Inspector(s): _______C__a_r_l _E_._W__e__ll_e_r_____________ (lead),_______C_a_r_o__l _C_h_e__n_________________ Start Time: 1__0_:_0_0__a_m__ ____________________________________, ____________________________________ End Time: 1__0_:1__0_a__m__ Facility Contact Information Logsdon Valley Oil Co., Inc. Facility Name: __________________________________________________________________________________________ Street Address:_____1_0__5__B_e_d__fo__rd__C__o_u_r_t__________________________________________________________________ City: ______H__o_r_s_e__C_a_v_e_______________ County: _______________________________ State:___K__Y___ Zip: __4_2__7_4__9_ Nature of Business: ______O__il_a__n_d__g_a_s__e_x__tr_a_c__ti_o_n__________________________________________________________ Facility Owner/Operator: ____L_o__g_s_d_o_n__V__a_l_le_y__O__il_C__o_._, _In__c_.__________________ 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__________S__p_e_n__c_e_r_W___a_lt_e_r_s__s_c_w__1_0__6_@__g_m__a_i_l_.c_o__m_________________________ Facility Contact (if different): _____E_ll_e_n__S__ti_n_s_o__n_,_P__re__s_id__e_n_t____________________ Phone: ______2_7__0_-_5_3__7_-_4_2_8__8____ O/O Mailing 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: _______________________________ State:___K__Y___ Zip: __4_2__7_4_9__ Well Data from File Clarence Wilson #3 Well Name & #: ________________________________________________________________________________________ Well Type (see table): _________P__r_o_d_u__c_e_d__W__a_t_e_r__D_i_s_p_o_s__a_l___________ State Permit: ______8_7__4_3_7_______________ Latitude (N): _____3_7__.1__7_8__7_1____________ Longitude (W): _______-8__5_._7_8__8_0_0________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; TubXing & Packer; Cemented Injection Tubing PBTD: Other: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): ________ Tubing Size (in):__________ Packer Depth (ft): ________ Inj. Zone: Open Hole; Perforated; Top(ft) ________ Bottom(ft): ___________ Max. Injection Pressure (psig): ________ Field Measurements and Observations Latitude (N): _______3__7_._1_7_8__6_5__________ Longitude (W): ______-8__5_._7_8__8_0_1_________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): ___A__C____ If not Active, Reported Date Last Active: __________________ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ 7_D__Q_N__V_K_R_Z__V__I_OX_L_G__I_OR__Z__LV__R_F__F_X_U_U_LQ_J___Y__LV_X__D_OO_\__WK__U_R_X_J_K__W_K_H__S__LS_H__ _______________________________________ 1__R__N_L_OO_S__OX__P__H__3__LW_V__D_U_R_X_Q__G_W_D__Q_N_V__K_D_Y__H_R__LO_\__V_K_H_H_Q__ ____T_u__b_i_n_g__G_a__u_g_e_:_______N__/_A_______________________ _'_U_L_OO__F_X_W_W_LQ_J__V_D__UH__V_H__H_Q__D_P__R__Q_J__WK__H__WD__Q_N_V______________P__r_o_d_u_c__ti_o_n__G__a_u_g__e_:__0__p__s_i_____________________ _______________________________________________________S_u_r_f_a_c_e__G__a_u_g_e__: ______N_/_A_______________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/OpeUraICtoInr sRpeepcrteosrentative (Optional) UIC Inspector Carl E. Weller Name:_______________________________________________ Name: ________C__a_r_o_l_C__h_e_n____________________________ Signature: _C_A_R__L_W__E_L_L_E__R_(_A_f_fi_li_a_te_)_D_a_te_: 2_02_3._08_.2_9 1_8_:03_:4_4_-0_4'0_0'______ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_3._08_.2_2_1_9:_15_:0_0_-0_4_'0_0'___ 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 EPA Well ID#: K Y S 0 9 9 0 0 1 2 Year-Month-Day: 2 0 2 3 - 0 7 - 1 8 EPA Permit # (or RA): K Y I 0 6 6 3 Phone: (404)562-9424 Page 2 Of 2 (Cont) ______C_l_a_r_e_n_c__e_W___il_s_o_n__#_3______E_P__A__P_e__rm__i_t_N__o_._K__Y_I_0_6__6_3_____S__ta__te__P__e_r_m__it__N_o__. _8_7__4_3_7______________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:_______C_a__rl__E_._W__e__ll_e_r__________________EPA Camera ID: __________S_X_8__1_2__3_____________________ Photo ID: ______2__0_8________Time: __9_:_5_9__a__m___ Lat (N): ____3__7_._1_7__8_6_5________ Long (W) _____-8__5_._7_8__8_0_1________ Description: _______________________i_n_j_e_c_t_io__n_w__e_l_l_c_l_o_s_e__-u_p_______________________________________________ Photo ID: ______2__0_9________Time: _1__0_:_0_0__a_m___ Lat (N): ____3__7_._1_7_8__6_1________ Long (W) ____-_8_5__.7__8_8__0_1________ injection well and tank battery Description: ___________________________________________________________________________________________ Photo ID: _______2_1_0________Time: _1__0_:_0_9__a_m___ Lat (N): _____3_7_._1_7__9_0__4_______ Long (W) _____-8__5_._7_8_7__8_6________ Description: ________________________ta__n_k__b_a_t_t_e_r_y________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Owner/OperUaICtoIrnRseppercetoser ntative (Optional) UIC Inspector Name:_____C__a_r_l_E_._W___e_ll_e_r_____________________________ Name: _______C_a_r_o_l__C_h_e__n_____________________________ Signature: _C_A_R__L_W__E_L_L_E_R__(_A_f_fi_lia_t_e_)_D_a_te_: 2_02_3_.08_.2_9_18_:0_4:_12_-0_4_'00_' _____ Signature: _ Digitally signed by CARL WELLER (Affiliate) C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_23_.0_8_.22_1_9_:1_5:_30_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18