Well Record Page 1 2 of "-kon WATER WELL Govemment Department of Environment DRILLERS FORM Water V-310 Reaourct1 Section Well ID:!'--::-:----:---:-----::,----,---::-:-::-:-----' YukonW.terW.11 Registry To be assigned Dept. Environment by Of Box 2703 WhltehorM, YukonY1A 2C8 Metric O 0 Imperial INSTRUCTIONS FOR COMPLETING THE FORM 4. Please print clearly in blue or black ink. 1. Additional information is provided at the bottom this form on of page 2. 5. Completion and submission of this form is the responsibility of 2. 667-3171. Question can directed Water Resources at be to 867 the drilling contractor. 3. 0.3 All well construction shall reported m measurements be 0.1 or ft . to 6. Please or imperial units for all measurements. specify metric WELL LOCATION AND OWNER'S INFORMATION A1 1...l ______ ~I Optional City (i.e. Well No. 2) Well Name: First Name Last Company/ Department/ Organization Name A2 Drilled For: .... !L_uk_e _______ ....,I .... f_oo_dwa __ rd _____ '----------------' of A3 Street Address Well Location: 11312-2 Echo Valley road Sketch of Well Location In indicate distances from sketch, property &ne, septic field, tank(a) and buildtng. fuel Please North Include arrow. A4 Town /Village/ Area/ Lott: 1...IY_u_ko_n_L_o_t _13_1_s-_2 __________ ...J A5 UTM Coordinates (using hand held GPS): NAD [Iill Zone 1 485038 E741925 '--------:-:--,:--:---------' Easting Northing ==----~ 43 A6 Elevation of Top Casing: !2 8 m (!l)ASL of 8 A7 Accuracy of GPS: 11 I +/-mi® AS Purpose Wells of Iii Domestic Test Well D D Irrigation D Environmental (Quality) D Commercial Municipal D D Observation - Water Level Other (please identify use) D Industrial Agricultural Public/Recreational D D D LOG OF OVERBURDEN AND BEDROCK MATERIALS are (All depths below ground surface, appropriate units, descriptors circle use provided) 1racs "< I°" (I.•. SILT""11Qgravel} -S01'1HJ" I0-203/. fi-•- SAND some grawl) EXAMPLE SAND, I I SAND) I I uturallld fb,own, black, ·silty 20-30% d-y g,9y, g,Hn, CLAY. SILT, GRAVEL, sandy gravely" .e. (i silty MOISTURE: moist (w•t) redish, beif,e, oiiw, yeflowWi} COBBLES, BOULDERS, BEDROCK ·50% scll= l-and sand" or ·and graver 35 ,--'HAR=;:;DN;;;Ea,5£=· 'chvd=I..:.-,,="""=--, ONLY brown I I I SAND rl ---:.-.-•• -.-,.-vo-,l~-.. -.,,.-.-::11,-t --,I f soft and saturated Dept,(m'\_ft_J EM GeMral Colour 85 Most Common Material Materials B6 Secondary B7 General Description B2From B3To 0 30 grey day rock grey gravel rocK sane K rs- IDlaC oearock r- - r- - r-- ,__ I--- r--- r-- ,- ,- ,- - - - r-- - r-- r-- - - r-- - B8 Permafrost Encountered: D NO DYES If yes, indicated depth ( m : ll!i): from C=:J lo: C=:J : Example WELL CONSTRUCTION /Continue• on P,,. zJ 08 26 DateWell po1s 2005 01 31 Completed '--v--v-v,,..--,v-,..,..--,M-:--::o--=-'o C1 Drilling Method D D Air Rotary (Conventional) Dug Other /please specify) D C2We11Type: ~"!'~===::• I! Reverse Air Rotary Cable Tool D I I OVEAOUADEN BEDROCK Mud Rotary 0 D (Hollow I Stem) Auger Solid Casing {dsp/hbo/owg,ounds,,rtaa,,pleuscilcJ6alJ<)w please Ct Diameter Seal: C10 Seal from: of Depth C11 Seal Depth C12Volume : to: Placed pO !id/cloudy Bacteria Testing YVVYMMDO Was sample laken? YES NO a 0 O 0 Moderately turt>id/cloudy If yes, indicate the the laborat name of ory. Date Sample Taken: Turt>id/cloudy 0 Electrical Conductivity: uS c=i Trace sand present D pH : C=1 YYYYM MDD - No sand present D Temperature: •c C=1 Water Chemic~ • of Well Olainfectlon Groundwater Type O Was a sample laken? YES NO EJ If yes. indicate the of name the laboratory. ple Was the well disinfected upon completion Date Taken: Sam Salty ol lhe pump inslallation? YES NO D D Sulphu, / Odour Egg 0 YYYYMMOO D Organic Odour Taste/ Briefly describe method well disinfection. of 0 Metallic Tasle ( D Other: (If applicable) \ CONSULTANT WELL CONTRACTOR 11 Name: ~-----------'~ Company \ I Ht Name of Contracto, Drilling Company: l f ock Solid Exp oration I Name ol Driller(s) M H2 :~rad agnuson 12 Company Address: ~=============ll 5 H3 Add,ess ol o,mer: lir"o"'se'==rac Whrn,'."te'i'h"'or"'se"""y";1;=a,;;O=es;;============l 13 Report Reference: ::===========.-~I 27 08 I I 4 Report Date: 12019 YYYYMMDD Signature Primary Driller of YYYYMMOD Date Submitted Environment to De 1. 01 ADDITIONAL INSTRUCTIONS Personal Information contained this Is collecled under the authority of !he on f01m Access to Upon tNa 29 be compile a COfllJleting form, Waler Resources Section (V-310), Section (c) and will used to Informal/on PtolBCtion Privacy (ATIPP) , and ol Act pleue mall Envl,onmenl, or lax Department of public database of and ground inlormalion. For further inlormallon contacl lhe It to wel waler : of Manager ot Hydrology, Waler Resources free within Government Box 2703, (667) -3223, ',\Jkofl at 667 10,1 Yukon itehorse, Yukon, Canada Ext Wh Y1A 2C6 1·800-661-