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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#: K Y S 0 9 1 0 1 1 9 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 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__:3__6__a_m__ ____________________________________, ____________________________________ End Time: 1__0_:_4_2__a_m__ Facility Contact Information Facility Name:_____W___e_s_t_K__e_n_t_u_c__k_y__E_n_e_r_g_y__R__e_s_o_u__rc_e__s_,_L_L_C_______________________________________________ Street Address:______3_8__3_0__V_i_n_c_e__n_t_S__ta__ti_o_n__D__r_iv_e_________________________________________________________ City: ____O_w__e_n_s__b_o_r_o_________________ County: _______H__a_n__c_o_c_k________________ State:___K__Y___ Zip: __4_2__3_0__3_ Nature of Business: _______O_i_l_a_n__d_g__a_s__e_x_t_r_a_c_t_io__n_________________________________________________________ Facility Owner/Operator: ____W___e_s_t_K__e_n_t_u_c__k_y__E_n_e_r_g_y__R__e_s_o_u__rc_e__s_,_L_L_C_______ Phone: ____2_7__0_-_9_2_6__-1__6_8__9______ Email: ________________________M__r_. _G_l_e_n_n__R__ig__g_s_,_p__h_o_n_e__: _2_7__0_-_3_1__6_-_7_4_8__7_________________________________ Facility Contact (if different): ___M__r_. _V_i_n_c_e_n__t_B__. _H_a__y_d_e_n_,__J_r._,_M__a_n__a_g_e_r__________ Phone: ____2_7_0__-6__8_3__-3__0_5_7_______ O/O Mailing Address: ___3__8_3__0__V_in__c_e_n_t__S_t_a_t_i_o_n__D_r_i_v_e______________________________________________________ City: ____O__w_e_n__s_b_o_r_o_________________ County: _______H_a_n__c_o_c_k_________________ State:___K__Y___ Zip: __4_2__3_0__3_ Well Data from File Well Name & #: ______M__a_r_y_M__a__d_d_e_n__-R__ic__h_a_r_d_s___#_W__-_1_____________________________________________________ Well Type (see table): ____E_n__h_a_n_c__e_d__O_i_l_R__e_c_o_v_e__ry__(_E_O__R_)_____________ State Permit: __________________________ Latitude (N): _____3__7_._7_0_7__7_8____________ Longitude (W): _______-_8_6_._7_1__9_1__7_______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing Other: __________________________________________________________________ Total Depth (ft): __________ Inner Casing Size (in): __4____"__ 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__0_7__9_2_5__________ Longitude (W): _____-_8_6__.7__1_9_1__8_3________ Elevation (ft): ____________ EPA GPS ID: _S__X_8_1__2_3_ Well Status (see table): ___A__B____ If not Active, Reported Date Last Active: ___2_/__1_3_/__2_0_1__3____ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): __W__e_l_l_s_a__re__l_o_c_a__te__d__in__R__e_y_n_o_l_d_s__S_t_a_t_i_o_n_,__K_Y__4_2__3_6__8___ __N_o__g_a__u_g_e_s__. _W__e_l_l _is__d_i_s_c_o__n_n_e_c__te__d_a__n_d__h_a__s_c_o__rr_o__s_io_n__._C_a__s_in__g__is__d_a_m__a__g_e_d__. _I_n_j_e_c_t_io__n__li_n_e__i_s_b__e_n_t_.____ __N_o__o_i_l_p_r_o_d__u_c_t_i_o_n_._T_h__is__w__e_l_l _w_a__s_a__b_a_n__d_o_n__e_d__fo__r_m__a__n_y_y__e_a_r_s_._______________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector 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_li_a_te_)_D_a_te_: 2_02_3._09_.0_1 1_6_:24_:0_0_-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_.3_1_1_6:_09_:2_8_-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 1 0 1 1 9 Year-Month-Day: 2 0 2 3 - 0 7 - 1 9 EPA Permit # (or RA): K Y A 0 3 6 2 Phone: (404)562-9424 Page 2 Of 2 (Cont) ___M__a__ry__M__a_d_d__e_n_-_R_i_c_h_a__r_d_s__#__W__-_1_______________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:________C__a_r_l _E_._W__e__ll_e_r_________________EPA Camera ID: _______S_X__8_1__2_3________________________ Photo ID: _____2_3_4__________Time: _1__0_:_3_5__a_m___ Lat (N): _____3_7_._7_0__7_8__1_2______ Long (W) ____-_8_6_._7_1__9_4__3_9_______ Description: ___________o_p_e_r_a__to__r'_s__s_ig__n__o_n_s_i_t_e___________________________________________________________ Photo ID: _____2_3__5_________Time: _1__0_:_3_5__a__m__ Lat (N): ____3__7_._7_0_7__8_0__9______ Long (W) ____-8__6_._7_1__9_4_4__8_______ Description: ___________t_a_n__k_b__a_t_t_e_r_y_a__n_d__o_p_e__ra__t_o_r_'s__s_i_g_n________________________________________________ Photo ID: _____2_3__6_________Time: _1__0_:_3_6__a_m___ Lat (N): _____3_7_._7_0__7_9__2_5______ Long (W) ____-8__6_._7_1__9_1__8_3_______ injection well close-up Description: ___________________________________________________________________________________________ Photo ID: _____2_3__7_________Time: _1__0_:_3_7__a_m___ Lat (N): _____3_7__.7__0_7__9_1_5______ Long (W) ____-8__6_._7_1__9_1__8_0_______ injection well farther back 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_l_E_.__W__e_l_le_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_.09_.0_1_16_:2_4:_42_-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_.31_1_6_:0_8:_59_-0_4_'0_0'____ Digitally signed by CAROL CHEN Version 2018-04-18