c-L 
Well Record Page 1  2 
of 
\(.kon 
WATER 
WELL 
GOWf'M'!enl 
DRILLERS 
FORM 
Well  : 
ID
0.pffl!Mnl 
of 
Erwlronment 
w.tar 
R 
.. 
oural 
hCUOrlV-310 
To 
be 
assigned  Depl.  metil 
by 
01 
Erwl
ron
Mon 
W•r 
W.N 
Reglltry 
Melric  lrnperbl 
O 
® 
8ol 
ZTUMlltlf'lone
, YulonY1A 
2CI 
4. 
Please 
pr
i in  ink. 
nl 
ciea~y  blue or black 
INSTRUCTIONS FOR COMPLETING 
THE 
FORM 
5. Completion and  of  is form is the responsibility of 
submiSSkm 
th
1.  i information Is provided at the bottom of  form on  2. 
Adcht
onl!II 
1h
is 
page 
the 
drilling contraclor. 
2. 
Q\Jesllon can  867 667-3171. 
be 
dlrecied lo Waler  ources 
Res
al 
6.  specify metric or imperial units  all  surements. 
Pl
ease 
for 
mea
3. 
Al 
well 
cons1ruction 
measuramenls shall be reporled 1 0 0.1 m or 0.3 N. 
WELL LOCATION  OWNER'S INFORMATION 
AND 
A  Well 
1  Opllonal (i.e. . 2) 
Name
: 
'"' 
-----~' 
C•ly 
Well 
No
Atll Nain,  st Name  I  0tqani1a!k>n 
La
conya
1:r 
I  I 
Oepartm~
A2 Drilled For: 
~_D_
E _tc_O_lfV_A_.:2~.D~S~~' 
_-P.>_Q_A 
__ 
~II 
~ 
''------------~ 
Sketch 
of 
W.11 
Location 
A3 
Street  Well Location: 
Address 
of 
I  I 
2. 
S \ 
R  O 
iv-E..Q 
12 
i 
VE. 
In 
sketch
, lndicale  lrom  H
dts\s1ce.s  property 
ne. 
MPfc: 
n.ld, 
kad 
tanlt(1)  budding. 
and 
PINN 
lrdud• 
Nonh 
urow
. 
A4 
Town IVUlage 
/"ArH 
/Lot#: 
.._I 
__ 
CA-
__ 
rZ. _ M A
_--'-
-'-
Ccc~_l(_~
c..._ 
___ 
~ 
AS 
UTM 
Coordinates (using handheld GPS): 
NAO 
[TITI 
Zone 
~ 
v,M 
--z_o
rv
(;, 
i 
Eastng 
N01lhif1g 
A6 
Elevatlon  Top  Casing:
of 
of 
!~----~' 
m.(wASL 
+I-
ml® 
A7 Accuracy 
of 
GPS: 
~-------~ 
AB 
Purpose  Wens 
of 
Iii  D 
Domestic 
Test 
Well  Irrigation 
D 
D 
Envir
'I.----=--------• 
0  O 
Commercial  Municipal  Observation - Water Lev Other 
D  D 
el 
(please idonlify use) 
0  O 
Industrial 
Agricultural  Public/Recrealional 
0 
I  I 
LOG  OVERBURDEN AND BEDROCK MATERIALS 
OF 
/All 
depths 
a,o 
- sumw,  . 
QIOUIJd 
.--,oprlare 
.,,,;15, 
use 
<»scrfplon. 
provldsdJ 
1r.ce"c Slt.T
1~fJ_. 
t,-ugr,-IJ 
·•oma·  .e 
10·
20"" 
(J
SAND~ 
gr.."'9J;I 
EXAMPLE 
~il""f. 
.. 
'Wn, 
~ 
ClAY, SJlf.  ,  - "'°'51'URE dry l mo.sll J 
SAND. 
GRAVEL
-.,1Sltldylgnwt,;20
:JO":. 
(to 
$11)/SANOJ 
u,.,..,,(-,
:fld&/\fJlll9R.~~ 
C086LE
S, 
BOULDERS, 
BE~ 
"
Mtduttrf0t•M:flgra..,r35-50~ 
HN«.Vi£ss__s;:.'fJ
""1d
/....,.,i-, 
ONLY 
? 
1
4
.._,. 
11 
SAND 
I 
._I 
---"'•ac=•,.R'aa.,..:•
'--..:•aaomo=slt"'---'I 
L! 
---'""'=..:;
--=-=..:;•
:a.
c_ 
__ 
_, 
64 
Genttll 
BIS.condaryMat11rt,t1,  O.acr1ptlon 
COk>ur 
BS  Ma\erlal 
Most 
Common 
B7 
C..Mtal 
~ 
~,,__"'1 
IJto.,.,-" 
(,/{h 
_, 
~ 
l.r 
~--' 
B8  Encountered: 
Permafrost 
D  D 
NO 
ves 
II  depth (  lo: 
yea, 
lndlcaled 
m  : •oo
/()
,: 
c::::J  c::::J 
,  _
WELL CONSTRUCTION 
re.,..,.., 
on 
P,., 
zi 
Dat1W1II 
IOOSOtJ, 
Com~eted
~y-y_y 
__ 
Y_M_M--0-0~ 
C2Welllype
:  • 
~..,...,..-,.,_., 
.,. 
C1 
Drllllng Method 
Iii 
A.r 
Aol•y 
IC<>'MlfltionalJ 
O  O 
IJujj 
01h01 
(p/HS8 
spllCi(yJ 
NlWptlld.,clng:tOrl•~ed" 
0 
Cable 
Tool 
I  I 
Ja 
OVEFIRJROEN 
O 
B
EOAOCk 
0 
Auger 
IHollow /  Siem) 
Solod 
Casing, 
___ 
,.....__
,...._.._.....,, 
C7 
rlher 
Commonto  C•slng: 
Rog1Nf<ng 
I 
C30utlido 
c:p 
C4CulngMolorial 
C5i!1'fi11Th
lcknou 
C6C~lo
: 
Diameter 
(em@I 
~Sl•et 
Ian/€) 
~ 
I  I 
m 
0 
?
Pi.lM 
0
01h•
c:=:::J 
YO~
,Z
)f2Rn
.Gal2006





of 
Record 
Well  Page 2  2 
11 
/con,.,_,,.,.p,,,_ 
CONSTRUCTION 
WELL 
cifd• 
r.luse 
below 
(deplh  ground :wrtace,  81)0fopl'lllle unitsl 
Surface / Environmental Seal 
from
Seal 
Pb-
Seal:  C10  Depth  : 
of 
12 
Diameter 
ca 
llopttµo
Seal  :  C  Votumo 
C11 
Type: 
Matarlal 
Sul 
Cl 
m~ 
__,
___ 
._ 
!1m,@  I
/.,-0 
t} 
@) 
cm
I  )I m,@ 
I  !  ! 
__./.u;,;::>,c___,j 
_ 
._ 
JBentonlfe 
(l.e.aMlonif•J 
un1tsJ 
111 
approp,w
m. 
o
tMilstt 
-
SIJt1«•
ground 
~ 
(c»pt" 
Pack 
Gravel 
. 
.@)
ir
1d
yes, 
NO 
8 
:  If  i, .a1 ert deplh ( m 
Pack
Gravel 
C13 
Mate,ial type: 
in@,) 
mm
! 
ol 
diameler 
lnoicale 
C=:J  C=:J 
C=:J 
from:  to· 
YES  n,alerial:  / 
siica) 
1.
( e. 
Ola: 
Siu/ 
Daplh 
CII 
from;  to:  Slot  Porlonrtlon 
Depth 
Cl1 
,,,,;15} 
,. 
.. 
._, 
cJrr:,. 
,. 
.. 
., 
(dep/hbmwgtoundwrl•ca. 
lnfonnatlon 
Well Screen 
~Tho<J
!Im@ 
'74o/ 
I 
!1,.,{!)  ./n-,nl-€}s 
.pf 
Sc:rNn1.j 
,@,
rmn,1
. , 
hou
i==:Jr
!(m@ 
I 
!Im@ 
Scnien2.! 
Cl&ScrNnType 
C15Scr-Materlal 
C1'0u<aide 
Conrlnuous Wire 
,0 
Stet! 
[1J 
.l'C:lt.
Cfft 
Diameter  C  l  Stainless  Wrap 
.s 
,r;/
1rr
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rn,®i==:Jn
J1 . ~
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tm
l
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Plasl Perlotaled 
0  O 
C19 
Slotted 
_____ 
NIA  Sc:roon 
0  0 
L-------------------~ 
Hole 
Open  CommanlS: 
ID 
ou,o,j 
0 
STATUS 
DEVELOPMENT ANO 
WELL 
Estimate 
D5 
D1We11o...topedby 
Completion 
Heed 
Woll 
D2 
Static 
Slick-up  Well Yield 
Head 
Wen 
D3  D4  Water Level 
Ufitf'I} 
of 
tr,p 
{-,_ 
Surge81od< 
House 
Wei 
?
(e).i 
~1<4>•
I  ,
8
.19Ning 
W\'¥or 
~~ 
or~
Pkloss Adapt
D 
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A• 
Jon,ng ,  Llf!1 ng 
Ai 
l!l 
,m
L.....J ,© 
fll•dllJ 
bfl/ow 
ii 
neg~INe 
(Use 
PERMITTED) 
(NOT 
t 
OWeKPl
Baling 
?
" 
Pun,>
0 
co,,_I00) 
(well 
Nono  nol 
0 
to 
D8 Method 
Abandonment 
Well  Statut.  Used 
07 
_, 
__ 
r9,.._ 
OIiier 
D 
Yield 
Woll 
Eallmato 
ned 
lssk>
proper1y 
well 
lhe  decorM'l
Wos 
ljtt
Air •ng 
D 
Anal 
D6  Well Status 
YES 
0 
grout? 
0en1on1te 
1tn 
w
Baling 
0 
Nol 
Water Sul)pfy (in uoe)  In use 
D  D 
u.
1tKj 
Abundm
0  O ~ 
ONO 
by 
Siano 
0  {lleck-up)  0  Deepened 
S. 
YE Indicate Date: 
ti 
f~~:}tf:_,."1 
? 
ll-:.ortNlllt~ 
D 
"' 
,.,.,.,.*
# "·
0111er-,=-=-----~ 
Obs•rvation 
0  O 
~r•1IRecnrdl 
l1 
l~..tf•:t1•t1',e
tlku•
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OOM 
·• 1,a..f"Ondl
0Mt
y  y y 
M  D  D 
V  M 
DATA 
Drawdown/Rocovery 
ol 
.. 
Water 
Well  L 
F1 
AND 
RECORD  GROUNDWATER QUALITY 
TEST 
PUMPING 
RecoYcry 
Orawdown 
unJIS) 
cifCM 
g,ound, 
beJow 
dttpfhs 
(AM  appropt1JJlt1 
W••L•MI 
Tmo 
w.,.,.t.lM!I 
Tma 
E1Pumpinglestlntonn.tion 
~ 
tt 
I 
fltt 
J 
lJ 
trn/
•oJ 
tm
RECOMMENDATIONS 
"""'' 
0 (FWI.) 
0(SWL) 
Pu,rq:i 
Aecomm.  Depp,, 
1 
1 
) 
l1m@
I 
n n 
YYYYUM
2 
2 
Wa"" 
Slatic  LeveUSWl.l, 
Recomm. Pumping Rate· 
3 
3 
) 
!(LpSi!@,
I 
hm'® 
I 
4 
? 
lnlake Set at: 
Pump 
rate: 
prov<OO 
. 
llowing
II 
5 
5 
ml®l 
I  l<
!(Lps/~1) 
! 
10 
10 
ol 
Duralion  pump(ng: 
15  15 
LJhrsLJmln 
20 
20 
(FWL) 
Waler Level 
Final 
25 
25 
Tesl: 
of 
end 
at  Pumping 
l<m@ 
I 
JO  JO 
40 
0 
?
QUALITY 
G1 GROUNDWATER 
Conlent 
Turbidity/Sand 
50 
so 
Dalo 
Aoki 
Meuuremsn'5 
Dale  Taken. 
Clear 
?
60 
60 
lurt>idlcloudy 
Slighdy 
0 
Testing 
Bacteria 
YYYYMMOD 
NO 
0  O 
laken' 
Was a sample  YES 
Modoralely lurl>1dlcloudy 
0 
indicate the 
yes. 
II 
0<y. 
bo1af
la
ol 
name 
:  Dale  lhtl 
Taken
S3mpto 
01\ubld/cioudy 
us 
c:::J 
Elec~ical Conductivity: 
__.. 
___ 
~I 
_JI 
_____ 
._
I 
Trace sand present 
? 
c:::J 
pH: 
YVVYMMOO 
und 
No  prssenl 
D 
·c 
c:::J 
Ten,>erature: 
of 
il 
¦
l.-
¦
An
l  Water 
Chemie.a
Well D~infection 
Grvu-1a<Tr1>0 
D 
DYES 
Was a sample laken?  NO 
th& 
t9 
ic,
ind
. 
yv,s
If 
lhe well dl&inlecled upon complelion 
IMJ(...llftllDry 
Was 
the 
of 
Ti.ken
Date Sa'!'P!e  ~  name 
s111y 
?
NO 
D  D 
lhe PU"1' lnslallallon?  YES 
of 
_, 
__ 
_.II.__ 
____ 
!
._ 
Egg 
/  Odour 
S<Aphur 
0 
YYVYMMOO 
Organic Taste/ Odour 
0 
""" 
ol 
fflfllhod  dlslnlecllon. 
ibe 
deSCl
8'11JMy 
Taste 
lG 
Metall
? 
:I 
Olhe<
D 
appllcable/ 
/II 
CONSULTANT 
WELL CONTRACTOR 
~-----------~ 
Ltd
Re
Water 
nway 
Cat
Co"l)any
Ulng 
O,
t 
ol 
1 Name  Contractor  ! :  !K>urces  . 
t-,1
I 1 Company Name: 
,;,
ony §!aaUe=E=V=E=R=S;;E=p;c;ae=;=a===;a;;,z;==;=e;;e=======l 
>;,;;
I 
C•
Dr••
ol 
Name 
H2 
..i 
--=---
~1--=-==-=
12 Company Address: 
2Z7 
Y1A 
YT 
Roe 
opper 
101 
,: 
ofDnlle
Mdress 
HJ  B C , \1Vhiteh0<se, 
=,-~ 
==========
~-
Aefefence: 
Report 
13 
Roport Data: 
? 
I
MMOO 
V
VVV
YYYYMMDO 
t-M'lfOfl~
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Ill 
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h.>t
11"5. 
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mialn
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11
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Pc1
INSTRUCTIONS 
ADDITIONAL 
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