Well Record Page 1  2 of 
WATER WELL 
DRILLERS FORM 
Well ID: 
Dtptrtmlnt or Etwfronment 
Weier RHOUl'C .. lee.Han y.:,10 
To  be  assigned  by Dept.  01  Environment 
-W...Woil llotlSlf\l 
Melrlc  O  lmpertal  0 
Boa  2703 WIIR•'-· Yukon Yf A 2c, 
4. Please print clea~y  blue or black ink. in 
INSTRUCTIONS  FOR  COMPLETING THE  FORM 
5.  Completion  submission of this form is the responsibility of and 
t. Additional information  provided  boltom  this  page Is  al the  of  form  on  2. 
the drilling contractor. 
2.  867 667-3171. Quesllon  directed  Water Resources at can be  to 
6.  for all 
Please specify metric or imperial units  measurements. 
3.  All  wen  construcllon measurements  be reported  m or  It. Shall  to  0.1  0.3 
A1  Well  Name: l  ,· ..  Optional  (I.e.  c,ty wea  No.  2) 
WELL  LOCATION  AND  OWNER'S  INFORMATION 
-------
First  Last Name  Oepnrlmenl  Organ1za1.,,. Name  Corrfp 4oy I  I 
A2 Drilled For: 
--'I_A~-~-<~E~ __ !lo' B\Q.1E.N  T'-l ------~~--
Sketch of Well Location 
A3  Street Address  Well of  Location: 11 \..\0  Du N  N cA- ROAQ  I 
In  sketch, Indicate distances  lrom  praperty n, 
seplc Ueki,  fuel  lank(•) and buildin!I, 
Please include Norlh arrCM. 
A4 Town  /Vlll~e I Al.ea/ Lot#: j  ~ - \·; ..  Gc::,~,rorV)  'j 
A5  UTM  Coordinates (using handheld  GPS):  NAO  Zone  c=J. 
Easirng ·  Northing 
m 
Elevation ofTop  Casing:;,
of  ...,! ,--___ _,!  ~L 
A6 
A7  Accuracy  of GPS;:~I - ~-----""'---'-'=--'J  +/· m I® 
Purpose  of Wells 
A8 
Iii  Domestic  Well D  D 
Test 
Irrigation  OEnvir 
D  D Commercial  Municipal 
D  D Observation • 
Water  Level  Othe t\ .,........, ,,.er,my,t1sw 
Industrial  Agricultural  Public/Recreational 
O 
D 
t  I 
LOG OF OVERBURDEN AND BEDROCK MATERIALS (All  below  circle appropriate units, use depths  are  ground sUlface,  descriplors provldodJ 
........,_  .,.___  :• 1------~- .... -----~---i ~----"'---'---~-'-I t---------'-~-; 
-- : ,..._  1---~----i 1--"'----'------·r-------------; 1"1, __________ --1 
-- ...__ r---------1 ,_ _______ .,.,  ~---------- t------------t 
, 
I"---- ·'·1-------~--1 i;--------1 .... -----~-'-------'-! ,-----------1 
' ~ 
i---.- :1----------1 r----- .----1 r------~-'-----, r------~-----
-
B8 Permafrost Encountered: D NO  Ovcs 
II  yes , Indicated depth ( m  :_,®: ~om:i::::::i  to c=:::::1 
WELL CONSTRUCTION  /C••- on P•g• 1/ 
, 
ExampJe
2005  or  sr 
0 
. 
C1  Drllllng Method  iii Ai;  Rotary  (Convenllonai)  O~g 
oil,~,  {pleases,-Hy)  C2We11Type:  ,..;,., .. goologlcalmal~b ... . 
. 
I  I 
water  pn:,dug,g zone  localtd"f 
D 
Rowrse Air Rotary 
Cabla  Tool 
D 
.  , 
OIIERIII/AOEN  ' ~OIIOCI( 
0  MudRotery 
Auger  (Hollow/  Solid  Stem) 
0 
Casing  /deptl,llofowgrount1sutt«,.p14.,.cir<;1eopproprl,t•units/ 
C3  C4  C5 Outalde  Cuing Materlal  ,•:l1ai1Thk:kl)fl0' 
_ ,i:. C~Ct•iB. tht
.  .  .. ,o 
Dl1mot1r  ( cm,@J  I ~=•~----,  _ ..  ..,.,E) 
0th .. ._j __ __, 
VO{S302)F2  09/2006 An
.





WELL CONSTRUCTION  {CanUnwd(n,mP, .. 1/ 
Well Re~orcl  _ 2_ Page~ of
Su rfaca / Environmental Seal  (depth  below ground  surfi!co,  please circle  apr;irocirlale  units) 
CS  Sul Ma!a<lalTyr:  C9 Dlamet,,  Seal:  C10  from: of  SN,&ith 
C12Voluinn Placed: 
_ CffS111 Di?-ID: 
.__ ___ __. .l m' ,© 
jBentonue  _  I  I . . {'ii  Hcm,@f  ..  icm© 
' --- ~  . I'(,  l!m@ 
(Le. Benl~I•) 
Gravel Pack (dlpth bllow QtOUnd su~. p1e,u a,c1r, appropnate units} 
C13Gravel  llyes. indlcoled deplh ( m(ij)): 
Pack:  ·a NO 
) 
YES  Indicate diameter of materiat- ( mm, from:  to: t::::J  t::::J  c:::::::J  1r@1  !Aalerlal  type: 
l.e.s\Dca 
Well  Screen Information (deplh  bolowg;ound su,lau, •-• ,,;~ ,.,;_°""'"' 11111,J  CH Depth  C18  to:  Slot  Pvrlorotion Dlo: from:  ..  O.pth  --- Size/ 
·  _ _  _  ,
Screon1.c=::J(m@J  i(m@[::::Jn,ou lmml;~ 
C140ullide  C15ScrHn Material  C16ScreenType  Screen2.c::::::::J(m@ t::'.:::]1m@ c=)Thou lmml,0. 
.
.Q 
Diam1t1r  (  Wi .  - - ·  · 
A!Ql  O Slalnless  Steel  Conlinuous  re Wrap  ,· -·  r---, 
c:::::J  cm""'  D  ll  l Steel  Screen  Scroen  m 
[l Louver  3,j ·  © - ./  _ --- m@  c:::==:J  ~Thou mm  I,@,,
D  O Plastic  Perforaled  ·  -
0  O NIA  Slotted  C19 Screen  ·  -
-- -- .. 
D  ~D Open  Hole  Comments:'---------'------------------_, 
WELL  DEVELOPMENT  AND  STATUS 
.w.in 01 O..elolMICI '~  D2Well  Head  Completion 
os ~iml!\II 
_ W,IIYleld 
Block  ·  wen  Ho\lle 
J. ·2) - tl.l>Si@.) 
_  _ 
__  , 
,nng  01'\tiirssAdaPll>r~...;.;.
lilAir~, l .  . 
olllng A!fµfting  (__Jtm'® 
B;Jlling '  P!) '1/tll  jN(?T  PEl\\llTTE[i) 
D8  Med10d  Used to 
.
B=c  Of:lonn(Well qci!'~~tell}  D7Wetl  Abandonment  St1tuo 
Es  Well Yield ff mate 
Was lhe  well  properly  decommluloned 
l»Airllltlng 
D6  Final  Well  Stalus 
Wllh  bentonlte grout? 
YES 
D  D 
·O •
Water Supply  (In  use) Not In  use  Abandoned  D o,y 
ONO 
: 
Stand  (Back-up) by  Deepened  ,.-,...,  Oa.,,_ i.,  ...  , 
D  .O 
II  Dale: YES,  lndlcale 
D  0 , - - ·J Observatloo  .' 0ther~,,=-- "' "'
PultwJlngTulReotdJ 
.  - I  l 
YVVVMMOO 
F1  Well  DATA 
Water Leval Drawdown/Recovery 
PUMPING TEST  RECORD  AND  GROUNDWATER  QUALITY 
(All depths  dR:ltt app,opna/e below (ltOUtrd.  uniu)  Drawdown  Recovery 
Ttme  W•ler L.....,  Tkne  W,1,_, ltlWII 
E1  Pumping Test Information 
RECOMMENDATIONS  _ _  _ /nmJ (hlJ M ,
-'  mwt)  (m fHJ 
P,umpi .11gT0st Start  Date :, 
0  :  '0 
{SWL)  (FWL) 
.,Recomm.P~ Dii@)! 
1- I 
1  . 
J' - f(m.@I 
YYYYMMOJ), 
:i 
Stauc Water [:eve!  (SYIL)
: 
Recomm.  Rate: Pumping 
r·  ,- -.,  -.  i(Lpsl@>) 
, -~
----~(ml€) 
Pump  Intake Set at: 
provide rale: 
H  .. 
I  _ __ J<m-'® 
iiLpsli@i) 
i' 
10  10 
Duratkln of lJUl11)ing: 
15  15 
OhrsOmin 
20 
Final waler  LM (FWL) 
. al  Pumping Jest: "'111  of 
.
J  !(ml@ 
40 
G1  GROUNDWATER  QUALITY 
i'u~ldlty/Sand  Content 
Field D111 
-~  1 
b Clear  :t.  1.,  ,·\.._ 
Date  rOment§.'tiken: 
~USU
-: so
: . 
-d 
0 
Sli!ihlly  turbid/cloudy  • 
eac1,r1a  .:  v 
Teatlng  .,1,  : 
vvvv · · o MMo
D 
Moderately turbid/cloudy 
a 
Was  taklln? sample  YES ·  II NO  yes.  fndalo 11>8 
D  0 
Turbid/cloudy 
D 
EleclricaJ ConducU\llty: c::J us 
r·~:1:~~•k eii;;,  l ;J name  of lhe laboralory. 
D Trace  sand  presonl 
pH:  'c;;;:::J 
.  Y  M" M  D  D 
·y  y· I/  . 
No  sand presenl 
D 
~•lure: c:::J ·c 
Chemlc1t Analyala  o!Water 
Well 
DlIlnfect1on 
GroundwllerType 
sample  taken?  DYES  O NO  yes. 
Was a  ndicalo 
II  the 
Was  the  well  disinfected  upon complelion 
Osatty 
Dale '.sample  /abonllory. Taken:  name  lhe 
ol 
ol  lhe pump  1n,1alallon?  YES  NO 
O  O 
Sulph  / Egg Odour 0  .. 
I  - I  I 'I 
'""'.'Yc--,Y,,.-..,.Y,-vc-'-"Mc"', -i,t.,-~
o~o-' 
D Organic  I 
Taite  oao .. 
Jjrlelly  . 
cl<lscribe  mathpd al weY  dlslnfl/cfk/11
D 
MetollcTute 
Other:( 
-
I  I. 
WELL  CONTRACTOR 
CONSULTANT  (II IPPfk:•bleJ 
. 
11  Name:  i--'----~~ ...... ---; 
Company 
y 
. 
HI  Name  Conlract _ 
ol  Wate~gsources Lid
H2Nameol~); 
12 Compeny Addreso;r ·
._,;....., __ ,..._,......,"""_~, 
H3  Addr866  ot  Driller: r.il!'~~"ii':':'5"ffir:!Et==::':'~!r."f'~====j 
' ,
IS Report  Reference: ~- ~====:======:::;;:~-:-:1 .. '. 
1
I  -~  --
14  Aaporl  Dale:  ~1 _.....;..~-------~-'l 
V  .  Y y ··y ···
!A  '·D  . D 
M 
Y  Y  V  Y  M  M  O  0 
"Otli d
Subri1itt lO 
11.  M°vw'ami.ri
S r 
·
ADDITIONAL  INSTRUCTIONS  Personal inlorma~on  i:oiiialned  on  1h11  lotm  Is  coltecltd  Undlr  the  •Uthorl1y  ol  lhe ~u IO 
UJ>On  compiellng lhls lorm,  W•ler Auourc•• s.dlon tV-310), 
lnlorm•lioll and PtOlecllon  (A1IPP) ol Prl~  Ac:I.  SocUon 29  (c)  and  wiM  be used  lo  a 
compile 
pa. mal o, ru ii  to:  Oeparlrnanl  ol  Em•in;inmtnl, 
118 
GOYernment  ol  t
'r\.lkon BOI  2703, 
:.~:;~~~~,~!:. ~n;::~=:~: !1;;;~':1~~~~~~::::~:;tact u,. 
Whllehor•, Yukor1,  C1n1rt1 VIA 2C6 
I-B00·661-<M08  Ell 3223. 
lo conlacl us leel free  at: 
Phone: (867)  Toi  'rukon): (1-800) 667-3171,  661-0408, local frH (in  31711 
!!:;-,.'t~~=~•ncf  ;i 
Fax  (667) 6G1·3195 E-mall:Wale,,AHUUrcu lg<N.'J'tl;il 
eolkctfan of,-11on,llnfonnatlon.'----'-'--s-,g-,-,1'-u,~• "';""w."'1",1 awn.,-"','-..;._~-=:..J 
.- _· · 
0