Well  Record  1  2 Page  of 
\(.kon 
WATER WELL 
GOYemmenl 
DRILLERS FORM 
Well  ID: 
O.partment of Etwttonment 
W•r RHClllt'CH 8"(1on V• )10 
To  assigned  Environment t>e  by Dept. or 
YukonWalarWtll Re~ry 
Metric  Q  Imperial  0 
em 270)Whie.hont.  2CI Y~Y1A 
4.  Please print clearly  blue  black in  or  ink. 
iNSTRUCTIONS FOR COMPLETING THE FORM 
5.  Completion and submissKln of this form is  responsibility of the 
1.  Additional lnformatkm is provided  bottom  this  page at the  of  form  on  2. 
drilling contractor. the 
2. Question can  directed to Water Resources be  at 867 667a3171. 
6.  Please  metric or imperial units for all measurements. specify 
3.  Al weH  construction measurements shall be reported  1 m  0.3 It. 
to  O.  Of 
WELL LOCATION AND OWNER'S INFORMATION 
Well 
A1  : (Le.  Wei Name '"' ----~~' Optional  City  No. 2) 
first  C -l O n Name  .Uw  I N.:1me.  omparty e)i-111ment  Digatriza. tio
A2 Drilled For: 
~L~E_c..~  l - t\-W___ _.l  ~1 <:X'O  I I----------~ .... 
Sketch olWell Location 
A3  Street  Location:! Address of  E:C.'.-10  VA L-l.°E::  Y  ~A!?! 
Well 
In  slcelch,  lrom nlcate dislaR:;es  p,operty hi, 
$0J!lic:  UeW.  ruel i.ra.(a) and  td<Jiny. 
Pliu• Include Nori, anow. 
A4TOMl 1V111age, A-, Lot ,:!'Lo,  \  / os\  -I BE:<  v'A LLE B 
AS  UTM  GPS): Coordinates (using handheld  NAD  Zone  CJ 
ViM  "U>V'\  t  \ 
Easting  Northlng 
4i l-)-:r'l.11> 
of 
A6 Elevation  Top of  Casing: '1---~-~I  ,@ASL 
m 
tt  :i,  Ll  \"\  3 1..-
of 
A7 Accuracy  GPS; ,__ _______ _.  +/- m I® 
A8 Purpose  Wells 
of 
Iii Domestic  Test Well 
Irrigation 
Envij ..._..._...,...---- - -
D  D Commercial  Municipal 
D Observation - Water  Other 
Level 
{plea se iden1 ity .UM/ 
D  D 
Industrial  Agricultural 
D 
Public/Recreational 
I  I 
LOG OF OVERBURDEN  BEDROCK MATERIALS 
AND  (All- a;s b8k>Ngrouna surface,  cln:l8app,optla18  aescrtp1ots units.  uss  p,twlde<J) 
0
ftat:it <tO"(l.o,SU.Tt,«.af¥.Jve,f} 
EXAMPLE  ,...,,,.·,o- ~•-SAND-,mol/· ar<
1 
ONLY  .  --.-:;:"~, ~~~~ - ~ ~ ~-~~,: :s.~ wo=Dt~:z~;:.;;:,:,~rJ 
SAN)  ........... _.,.  11  __ 
I  - I. I  II  .  ' ..,..., 
r--==,-x,..--, 
8' Secondary .... .,, ... 
Gentral Dacrlptlon 
84 General Calcwr  B5 Moat Common  B7 
Ma&fflll 
yes,  d~  1€1: ,;om: c:::::::J  10,c=J 
H  Indicated  ( m 
BB  Permafrost Encountered:  NO  YES 
CONSTRUCTION  re_-.__,, 
WELL 
E•~ 
D•t.W•H  a-·  t~ · a~: o'i 
:IOOSOt  31 
11 
eomp11Cec1  v  ,.  v  v· - .  o .... o· 
C1  Drtllng Method  Air  Rotary  (COIMUIUonal) 
Iii 
Dug 
... ,AOlary  0  Coble Tool 
OYER!lJROEN  jg_ BEOAO::t< 
0MooROlaty 
0  "1,ge, (tiollow / S!)lld Slam} 
Casing  r_,_.,..,,.,..._ ____ ....., 
C7  Commento R09~rillng·c : 
r .....  .01nv I 
C30uulde  c•CulngMat1tlal  CS~IIThlctuw!H 
C&C~to: 
_ 1851,.t Dlameler~ lcm,@  l...Lzt!]fr-.m/E) 
L.l...2Jlmt0





Well  Page 2  2 Record  of 
WELL CONSTRUCTION  rc-,,._,,~m,,,,.11 
Surface  Environmental Seal I  fdoplh below grouncf $l-1aee. p1case  lXlit$J clrde app,cpria:e 
CB  Seal  C9 Diameter  C10  Depth  C11  Depth to:  C12Volume Placed: MaterialT:r:  of SHI:  SHI  from:  Seal 
jBentonde  _  ,_ ___ __,(cm,@I  ..  1m@  I  .  lcm®  ,_ ___ __,·1m>,© 
(l.a.Bentonikll 
Gravel Pack (dtlplh  t,e,1ott- gtourwJ suriau. (JWH ch:e eppn,tJiU&I• unttsJ 
C1S Gravel  Indicated  : Pack:  0  NO  depth ( 11  yea,  m@)
:  :  Indicate diamel& of material:  I  Material type: DYES  from c:=:J  lo c:=:J  ( c:=:J  1n1n1  ir€)s  ·1------' 
Le.silica 
Well  to;  ,  Size  Perforation Screen Information ,~ i,.A,w grourtd surface.  pw crGJe IIDP'OP'~ia unilsJ  l;:17  Depth from:  C111  Depth  Slot  Dia: I 
58 
Screen  .@ ,1.c==::J(m@ c:===:J(m c==:J 11,ou,I  mm  I,,@., 
C14O- C15Sc,..,,Material  C16ScreenType  @  '
S  ..---,(  .(jj)  ..---'-,(  c==:Jn""'  i;,@, 
1 
2 
Diameter  (  Stainless Steel  Conhnuous Wire Wrap  ·  m  s I@)}  D  creen  L----J  L-----J '"  ,  ·  mm 
,
c::=J. cm  D  D Steel  Louver  Screen  :
ScrNn3.c::=:J{m@ c::=J<m.@ c==:JThou Jm m/1~s 
Plastic  Perforated  ;=!-~~===~=~~~~~~~===~=~~~~~~=======~~ 
D  D 
NIA  Slot1ed  C19ScrHn 
0 
0  . OpenHo)e  Comments: Othor~ __ _,0  (_ ________________ J 
WELL DEVELOPMENT AND STATUS 
05 Well Yield  E•lirnate 
~ -
D1WelI  Hood SUck-up  StatlcW11or 
~lopod  D2w.tl Heod  Complellon  04  Level 
~1, .. 1Q,, 
~ -Slock  House  'T J.'  ,.,,-;.,,o1 ~, 
. .
8 
.,,,~i , •~ OPltlossAdaptor.-.z.,_  ~©  ~(m@ 
.  · 
(·
1
. · Airll/lfng 1:1A/r Je11,,g (. L_J( .. ,..,  -~  ··-,~-•(II  .  •"" 
. 
1
DweNPit(NOTPERMITTED'f  .,..,.,.,.., .,......tr __ ,  '"'  tJW"IJf-} 
,.,.,.....  ' M 
'EJ  None (well not completed)  07  W.II Abandonment Status  08 Method UM<I  to 
D 
Esllmate  Yleld wen 
was  properly decommissioned tM well 
l9 Airlifting 
06 Fina  I Well SUltu:s 
wn11  bentomte grout?  DYES 
Water Suppty {in  AbanOon8'J use)  Nol iri  use  Orf 
D  D  D 
ONO 
Dfw~'_,.,.,. 
U  .lndtcale YES. OaJe: 
by  (Back-up)  Deepene=•'---- ,,  ..,,.,......  PrlQf OU.1,1,y 
D 
~T-~ 
O~tlon  O~r~ 
01utt1"v,c:Olld4l,i,,11 
Y  M  -M  O  0 
- y 
Y  '( 
F1  Well Wiler Level Orawdown/RecOYe,y DATA 
PUMPING TEST RECORD  GROUNDWATER QUALITY AND 
Drawdown  Recovery 
(AMCMpt.._,..grovttd.dtdtl•p,proptrllJt!IJllbJ 
E1  Pumping  Test Information 
Im~.  W.::/::.,  I=  1':1~-:' 
RECOMMENDATIONS 
Pu"'f"n9 ioM,siart Dale: 
O_ (SWL)  !F)IVI.) ··
o 
I  .  .  . .  . -
Recomm.  Depth: 
Pump 
I  jr.
m@1 
YYYVMU : ' D l:)
2  -
Static Water Level (sw()! 
Aecomm.~~ -~ale: 
3._ 
)<Lpsl@I 
I 
,I  - -- _l(m/<!i) 
~at: 
.P.uri!p~ln\ake 
.11  Howing,  prCJV?de  rate: 
j(m,@ 
J ,  - -
._ ____ _,(Lpsl!la),J 
10 
10 
D<ntionol""""'ng: 
15
_ 
'~ -
01wsOmln 
20 
20 
Final Waler L_ {FWL) ewl 
.  2_ 5 
25 
:aten:c, __ Of P~T~I: 
30 
30 
I  ;l~m-© 
40  40 
01 GROUNDWATER QUALITY 
50 
TurbidttylSand Content  50 
fleldDola 
60 
60 
oaia:~lSTilka'n: 
0  Sllghlly lurbWcloudy 
Bacteria  Testing 
a sample ~ken?  YES Was  NO  ,r )'OS,  Indicate the 
0  O 
YYYYMMOD 
Moderalely ""1>1d/cloody 
0 
Dale S!"J'le Toien,  name  of 1/18  JabotalO<)< 
,
OTurt>id/cioUdy 
Eledrlcat ConducilYlty: c::=:J US 
~I_  . 
..,.,....,.· ·  =-:-·· -~t ~I ___ _. 
Trace  sand  present 
D 
. 
pH:i=:J
YYYYMMOD 
D 
No sand pt'6'8n1 
Tampe,atura: i=:J ·c 
Chemical Analysis of Water 
Well Olatnfeeuon 
Was 
0  D YES  ff yes.  lnclcate the 
a sample taken?  NO 
Gn>-Type 
Sa _  _
Dale  -
mp'8 Taken:  ..  name  t  o_thtt-~
Was  the well  upon c001)letlon dlSlnfecled 
Sally 
o1  !he  pump  lnSlalla!IOn7  YES  ND 
0 
Sulphur/ Egg  Odou, 
..,_I -==,-,,-;:-,--...,,,-!I  I~----' 
·f 
··o~ 
·v  v  ~v  o 
Organic  /  >
Tasia  Odour  Boolly~sc, ... mo/llO<l!>f ...,,d/SJnlfflk/fl. 
on,e,:I'"";  ., ___ 
I 
CONSLl.TAkr ' -/il~~-'-1---------~ 
WELL  CONTRACTOR 
Company 
I 1  Neme: 
I  - .~
2CompanyAddress: --=-----==~ 
13 Report Aeietence:  =========;----' 
Dale
I 4 Aeporl  · 
l·  Y  Y  M 
M  D  0 
y · ··y 
M  M .  D 
Q 
OI EmMonment 
I.  . 
Per.son  inlonnation coolalned  lo,m ..  mi  lhis  la  col1&ctod  unl.ltrf  the 111U1hority  ol  11\a  M:CIPS:\  IP 
ADDmONAL INSTRUCTIONS  ' 
'
llllormabon ana PrOl«tlun  PtlllilCl' (AOPP)Act, ol  Sec.lion  20  anti  ,onlpllo (o)  WIU  be used lo  ill 
I 
Upon~ttilt:lorm,  Walft~&~on(V.310), 
pu~~ 1.M.tlau ol wel ~nd  For 1uither lnklfmllllon contillci l>'CAA'ld  w,11a  ldormalkln.  lhe 
p6nsem,ll01fultto;  ~==:~:n°'::"'i,
, 
Me11ege1  ol  ,  al (867) 667·3223, loll lreo within Hydtl)IOtJY Waler RMourr.e6  'rukon 
03
,  VIA W~ileho,u 'l'\Jk,on,  Ca,,ada  2C6  1-800·661-0408  J223. Ext 
INN tNd  aboWi clauu Md 
PleNe S.. free  conlact  Ille 
10  U&  al: 
,_ _____________ __. 
Phurw. (867) 067•3111, Toi  {ln'l\lkuri): (1·800i 661-0,(00,  i'1J lree  locll 31 
signature  Ol\ll'ler of  Well 
F.,-.- (Soi') ti67•3HIS  :W~hlf.~W',IJIJl'CU.90",yk.U  eol#cliono/f#1Son.alWorn'Ufllon. 
E-m.Ml