Document zkKgL8w0B8BMmOB2RBRkbGG7

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 0 5 Year-Month-Day: 2 0 2 2 - 0 9 - 1 3 EPA Permit # (or RA): 5 7 8 Page 1 Of 2 Inspector(s): Jason Rose ___________________ (lead), Page Cirillo_____________________________ Start Time: 10:25 AM___ ____________________________________, ____________________________________ End Time: 10:35 AM ___ Facility Contact Information Facility Name: Blackjack Plant ____________________________________________________________________________ Street Address: 4940 Blackjack Plant Road _________________________________________________________________ City: Jay ____________________________ County: Santa Rosa _____________________ State: FL _____ Zip: 32535 ___ Nature of Business: Oil and gas production__________________________________________________________________ Facility Owner/Operator: Black Creek Energy, LLC ____________________________ Phone: (601) 431-5386 __________ Email: harris.butler@butlerroyals.com ______________________________________________________________________ Facility Contact (if different): Michael Wetzel ___________________________________ Phone: (850) 324-6271 __________ O/O Mailing Address: 140 Virginia Street, Suite 402 __________________________________________________________ City: Richmond ______________________ County: NA_____________________________ State: VA _____ Zip: 23209 ___ Well Data from File Well Name & #: Albert Rosasco Etal #19_4 Well Type (see table): Enhanced Recovery (EOR) ________________________ State Permit: API # 0911320068 _________ Latitude (N): 30.837948N______________ Longitude (W): -87.07942W ____________ Elevation (ft): NA _________ Injection Method (check applicable): Casing Injector; Tubing & Packer; Cemented Injection Tubing PBTD - NA Other: __________________________________________________________________ Total Depth (ft): 16,250' ___ Inner Casing Size (in): 7" ______ Tubing Size (in): 2.875" ___ Packer Depth (ft): 15,660' _ Inj. Zone: Open Hole; Perforated; Top(ft): 15,828'_ Bottom(ft): 15,877' ____ Max. Injection Pressure (psig):2,500 psi Latitude (N): 30.838016 N _____________ Longitude (W): -87.079294 W __________ Elevation (ft): NA _________ EPA GPS ID: PG No. 3358766066 Well Status (see table): AC_____ 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): The pressure readings on all the gauges at this site read 0 psi. _ The site was clean and well-maintained. There was no evidence of leaks or excessive corrosion. Perfs (see well schematics): Original Perfs: 15828'- 15842' GPN July-72 Additional Perfs: 15841'- 15877' GRN Aug-76 Field Measurements and Observations _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log Owner/Operator Representative (Optional) UIC Inspector Name: Cliff Emmons ___________________________________ Name: Jason Rose ____________________________________ Signature & Date: see attached field notes ________________ Signature & Date:__________________________1_0__/_2_6_/_2_2___ 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 0 5 Year-Month-Day: 2 0 2 2 - 0 9 - 1 3 EPA Permit # (or RA): 5 7 8 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photographer: Jason Rose____________________________EPA Camera ID: PG camera ID no. 14 S/N:31029537 _______ Photo ID: 1 _______________Time: 10:27 AM ___ Lat (N): NA __________________ Long (W): NA___________________ Description: Looking north, Albert L. Rosasco Et al #19-4 sign alongside access road. ____________________________ Photo ID: 2 _______________Time: 10:29 AM ___ Lat (N): NA __________________ Long (W): NA___________________ Description: Looking west, site overview, including well head, pressure gauges, valves, and access stairs. __________ Photo ID: 3 _______________Time: 10:30 AM ___ Lat (N): NA __________________ Long (W): NA___________________ Description: Looking north, closeup view of surface casing pressure gauge. Pressure reading is 0 psi. ______________ Photo ID: 4 _______________Time: 10:30 AM ___ Lat (N): NA __________________ Long (W): NA___________________ Description: Looking north, closeup view of production casing pressure gauge reading 0 psi. _____________________ Photo ID: 5 _______________Time: 10:31 AM ___ Lat (N): NA __________________ Long (W): NA___________________ Description: Looking north, closeup view of internal pressure gauge reading 0 psi. ______________________________ Photo Log Owner/Operator Representative (Optional) UIC Inspector Name: Cliff Emmons ___________________________________ Name: Jason Rose ____________________________________ Signature & Date: see attached field notes ________________ Signature & Date:__________________________1_0_/_2__6_/_2_2___ Version 2018-04-18 Site Photographs Albert L. Rosasco #19-4: September 13, 2022 Photograph 1: Looking north, Albert L. Rosasco Et al #19-4 sign alongside access road. Page 1 of 5 Photograph 2: Looking west, site overview, including well head, pressure gauges, valves, and access stairs. Page 2 of 5 Photograph 3: Looking north, closeup view of surface casing pressure gauge. Pressure reading is 0 psi. Page 3 of 5 Photograph 4: Looking north, closeup view of production casing pressure gauge reading 0 psi. Page 4 of 5 Photograph 5: Looking north, closeup view of internal pressure gauge reading 0 psi. Page 5 of 5