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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 Year-Month-Day: 2 0 2 4 - 0 4 - EPA Permit # (or RA): Page 1 Of 1 4 3 0 2 Inspector(s): _____C_a__ro__l _C_h__e_n_____________________(lead),_____C_a_r_l_a__F_o_y______________________ Start Time: _1_:_4_0__p_m___ ____________________________________, ____________________________________ End Time: 1__:4__8_p__m___ Facility Contact Information 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__ Well Data from File McDavid Lands Etal #7-3 API No. 0911320025 PA No. 311581 Well Name & #: ________________________________________________________________________________________ Well Type (see table): __E_n_h__a_n_c_e__d_O__i_l _R_e_c__o_v_e_r_y__(E__O_R__) _______________ State Permit: __O__G___4__9_6_________________ Latitude (N): _______3_0__.9__7_7_0__5_6_________ Longitude (W): _____-_8_7_._1_8__0_0__2_8________ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 15,592' Smackover Formation 3 sets perforations Other: __________________________________________________________________ Total Depth (ft): _1_5__,8__4_6_'__ Inner Casing Size (in): 8__3__/_4_"__ Tubing Size (in):__4__1_/_2_"___ Packer Depth (ft): 1__5_,_0_6__7_' Inj. Zone: Open Hole; X Perforated; Top(ft) 1__5_,_4_8_0__' Bottom(ft): 1__5_,_5_4__0_'___ 7,500 psi gas N2 Max. Injection Pressure (psig): 4_,4_0__0_ps_i_P_W Field Measurements and Observations Latitude (N): ___3__0_.9__7_7_1__9_5_____________ Longitude (W): ______-8__7_.1__7_9_9__8_2________ Elevation (ft): ____________ EPA GPS ID: __S_7_5_5__3_2_ 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__)__________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _D_A__N_G_E__R_s__ig_n__p_o_s_t_e_d_:_H___S_M__a_y__B_e__P_r_e_s_e_n_t_.._A_u_t_h_o_r_iz_e_d__P_e__rs_o_n__n_e_l_O_n__ly_.._H_a__z_a_rd__o_u_s_O__p_e_r_a_t_io_n_s_._._K_e_e_p__O_u__t._..____ _T_h__is__w__e_ll__is__a_c_t_i_v_e_ly__i_n_j_e_c_t_in_g__p__ro__d_u_c_e__d_f_l_u_i_d_s_._T_h__e__p_r_o_d_u__c_e_d__f_lu_i_d_s__m__a_n_i_f_o_l_d_i_s__c_lo__s_e__to__a__w__o_o_d__e_d____ _a__re__a_._A_n__e__lo_n__g_a_t_e_d__p_o__o_li_n_g__o_f__fl_u_i_d_s__is__o_b__s_e_r_v_e_d____________T_u_b_i_n_g__g_a__u_g_e_:_________1__8_0__0__p_s_i__________ _d_i_r_e_c_t_ly__i_n__fr_o_n__t _o_f__th__e_m__a__n_i_fo__ld__u_p__o_n__s_a_n_d__y_s_o__il_, ___________P_r_o_d_u_c_t_io__n_g_a__u_g_e_:_______0__p_s_i______________ _b_e__tw__e_e_n__t_h_e__i_n_j_e_c_t_io__n__w_e_l_l_a_n__d__m_a__n_i_fo__ld_.___________________S_u_r_f_a_c_e__g_a_u_g_e_:__________0__p_s_i______________ ____________________________________________________________F_l_o_w_l_in_e__g_a_u_g__e_: ___________________________ 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._07_.0_9_1_0:_36_:3_1_-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 1 4 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______M__c_D_a__v_id__L_a__n_d_s__E_t_a_l_#__7_-_3_______________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________P_e__rf_o_r_a_t_i_o_n_s__(_S_m__a_c_k__o_v_e_r__F_o_r_m__a_t_io__n_)_: ____ ____________________________________________________________1_5__4_8_0__'_t_o__1_5_5__0_0__' _(6__S_P_F__)_1_2__/_0_1__/_2_0__1_8___ ____________________________________________________________1_5__5_0__0_'_t_o__1_5__5_2_0__' _(_6_S_P__F_)_1__1_/_2_9__/_2_0__1_8___ ____________________________________________________________1__5_5_2__0_'_t_o__1_5__5_4__0_' _(_6_S_P__F_)_1__1_/_2__9_/_2__0_1_8___ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Carol Chen S75332 Photographer:______________________________________EPA Camera ID: ______________________________________ Photo ID: __R__IM__G_0__0_1_3_1_____Time: ___1_:4__0__p_m___ Lat (N): ____3__0_.9__7_7_0__8_7_______ Long (W) ____-_8_7__.1_8__0_0_0__5_______ Description: P_h__o_to__o_f__th_e__i_n_je_c__ti_o_n__w_e_l_l,_s_i_g_n__w_i_th__w__e_ll_i_d_e_n_t_i_fi_c_a_t_io_n_,__a_n_d__D_A_N__G_E_R__s_i_g_n_:_H___S_M__a_y__B_e__P_r_e_s_e_n_t_._..__ Photo ID: __R__IM__G_0__0_1_3__2____Time: __1__:4_3__p__m___ Lat (N): ____3__0_._9_7_7_1__9_5_______ Long (W) -87.179982 ______________________ Description: ___s_u__rf_a_c_e__p_r_e_s_s_u_r_e__g_a_u_g_e__r_e_a_d_s__0_p__s_i _______________________________________________________ Photo ID: __R__IM__G__0_0_1_3__3____Time: __1_:_4_4__p_m____ Lat (N): ____3__0_._9_7_7_1__9_5_______ Long (W) ____-_8_7_._1_7_9__9_9_8________ annulus pressure gauge reads 0 psi Description: ___________________________________________________________________________________________ Photo ID: __R__IM__G__0_0_1_3__4____Time: __1_:_4_5__p_m____ 30.977107 -87.180086 Lat (N): _____________________ Long (W) ______________________ injection tubing gauge reads 1800 psi Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ U IC 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_:3_6:_57_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18