Well Record Page 1  2 of 
W€ 7--
WATER WELL 
"kon 
Govemment 
Department or Environment 
Well ID: 
DRILLERS FORM 
Water  V-310 Resources Section 
Yukon WaterWtll Registry 
To be assigned  Dept.  Environment by  Of 
Metric  O  0 Imperial 
Box 2703  Yukon  2C6 Whit9horM,  Y1A 
INSTRUCTIONS FOR COMPLETING THE FORM 
4. Please print clearly in blue or black ink. 
1.  2. Additional information is provided at the bottom of this form on page 
5. Completion and submission of this form is the responsibility of 
2.  867 667-3171. Question can be directed to Water Resources at  the drilling contractor. 
All well construction measurements shall be reported to  m or  Please specify metric or imperial units for all measurements. 
ft. 
3.  0.1  0.3  6. 
WELL LOCATION  INFORMATION AND OWNER'S 
A1  L! ______ __.!  Optional  (i .e. Ci1yWell  No 2) 
. 
Well Name: 
First Name 
Last  Name 
Company/ Department  Organization I 
A2 Drilled For:  Ljc_h_ri_s ________ ~j LjK_o_st_e_ln_ik _______  L-----------------
1 
A3 
of Well Location:  Street Address  Sketch  Location 
1 Couch road 
of Well 
'--------------~ 
In  Indicate dlstances from sketch,  property Ina, 
septJc field,  fuel  lank(s)  and build,ig. 
Please Include  North arrow. 
A4 Town /VIiiage /Area/ Lot#: ._IH_id_d_e_n _v_a1_Ie_Y ___________ ..., 
c-- Wt",  ccil  G,  PS: 
AS  Coordinates (using handhold  : 
UTM  GPS) NAO  [Iill Zone 
c.\of,ut  'jveu 
1510338 
f744565 
VTNl  "2-0vH 
Easting  Northing 
2 _ 9 
10 _
A6 Elevation  Top  Casing: ~1 ____ ...,I  m 
,@ASL 
of  of 
q.~qc,11~ 
18 
of 
A7 
Accuracy  GPS: ! +/- m I® 
tt  :,.q  IJ.S-(,S" 
---------~ 
of 
Purpose 
AS  Wells 
l!I  Domestic  Test Well  Irrigation  Environmental (Quality) 
D  D  D 
D  D Commercial  Municipal  Observation • Water Level  Other (please identi  use) 
D  D 
D  D  D 
Agricultural  Industrial  Public/Recreational 
LOG OF OVERBURDEN  BEDROCK MATERIALS AND  /All  are below  surface. circle  units, use depths  appropriate  descriptors provided) ground 
'trac." <10%  SILT  gravel} {1.11.  trace 
~sonMl" 10-20% (ie. SAND some gr.awl) 
EXAMPLE 
tb,own, grey, green, blaclc,  CLAY.  SILT,  SAND,  GRAVEL, 
"Silty I  I  SAND) sandy  grawly-20-30% {i.e. silty 
MOISTURE:  I  I dry  moist  ulutalad (lfft) 
rwdish,  beige,  COBBLES, BOULDERS, BEDROCK oliw, yellowWi) 
" {JftJWI" and sand' OI'  35-50'% 
HARDNESS:  I .salt  hanJ /wry hard 
ONLY 
brown  I I  SAND  II  trace aravel  someslH 
soft and saturated 
II 
DepOl(m(ft} 
1W  General ColOt.lr  85 Most Common Material  86 Secondary Materials 
87 Genenil Descrtption 
....... 
B3To 
a 
15 
grey 
silt 
Iurown  sanu 
rrs--
grey 
1e1ay 
SUI 
lflo 
rr,ii-
sano 
Siu 
gr!!Y 
rm--
tf3g 
grey  grave,  sana 
rm-
,_ 
,_ 
,_ 
,___ 
,___ 
-
,_ 
,__ 
- -
-
-
-
- - - - - - -
88 Permafrost Encountered: D  Oves NO 
II  indicated deplh ( m  :  lo: yes.  I© from:  c:::::J  c:::::J 
WELL CONSTRUCTION tcon-. on P•r,e  &amp/a: 
z1 
08  28 
DateWell  12019 
Completed  LL _________ __. 
20050131 
VVVVMMOD 
C1 Drilling Method  Al,  Dug Rolary  (Conventional) 
D  D 
D 
Other  /p/eaH spac/fy) 
C2 Well 
Type:  :::::•~...,"':'=::• 
(!I  Reverse  Cable Tool  !  I 
Al, Rolary 
D 
0  O 
OVERBURDEN  BEDROCK 
Mud  Solid Rotary  Auger  (Hollow  Siem) 
D  D 
/ 
Casing tdsplh-grouoo surraa,,  p1eue """"'.,,,,,,,,,,,.,. units/ 
C3  C4  CS Outside  Cuing  CHlng Wall Thlcknna 
C8  Ct•lng Defth  to: 
(ISINI  (]g[:J(cm/€) 
134  ( mi(i) 
Pi.atic 
D  Oth•r  r----, 
YG(5302)F2  . 
Rav OQ/2006





Well Record Page 2  2 of 
WELL CONSTRUCTION  /Continuo,u,.,., P,,,. 1J 
Surface /  Seal Environmental  (depth below  ground  su,tace,  please circle appropriate unils) 
Cl Diameter  C10  Depth of Seal:  Seal  to: from:  C11  Seal Depth  Placed: C12Volume 
C8  Seal  Material Tyr: 
,C,Sm  bentonite 
i,o  1<=@1  10  l<m©  ~o  I Im,© 
~---~(rn',© 
(I.e.  Bentonlte) 
Gravel Pack , 
__ r,ourrd.,,<tace.  p1easec1rc1eappropr1a1e  umsJ 
C13  Indicated depth ( m Gravel  Pack:  NO  If yes,  .@): 
0  YES  from:  lo:  lndlcale dlameler of material:  )  Material c::::J  c::::J  c::::J ( rm, i lr-0s  type: 
i.e. silica 
Well Screen lnfonnatlon (depth  groond below  surlace.  please c1n:1e •-•• units)  C17  Size Depth  Depth from :  : C1B  to Slot  I  Perforation  Dia: 
Screen1.j134  tcm® '139  t(m.@  ~Thou./nvn/~ 
I 
C140utslde  C15ScreenMaterlal  2
C16Sc[!JroeConnlyti·npeuousw·,reWrap  Scroen .t  tcm,©  tcm,©  ~Thou./mmn,@,s 
Diameter  ( 
'°""I  [!l Stainless Steel 
an""  0  O Steel  Louver Screen  3. Screen  I  I  I  ( I<  ®  ,© c=J Thou./ mm/ ir@,s 
m  m 
Plaslic  Perloraled 
C19Screen 
N/A  Slotted  Comments:._ __________________ _ 
0  O 
Olherrl ---..,,n Open Hole 
WELL DEVELOPMENT  STATUS AND 
D1  Well  Developed  by 
D2 Well  Well Head  Completion  Static  Yield Estimate DS 
D4  Water  Level 
D3 Well Head Stick-up 
0  Surge Block 
OWe11House  (,.,,_ top olc..'"'1} 
(above II'°""" .urtx.} 
t24  tcLps/Q,) 
D  Water Jetting 
@ Pitless  Adaptor~ adapfor: 
t14  tcm@ 
12  l<m@ 
C!I  Air  Air Jetting/  lifting 
e......._J(m@ 
(Uu, ntJQBllve  If 
(Use  grade)  grade) 
negative  ff below  below 
Pil (NOT PERMITTED) 
l!l Pumping 
0  None (well not completed) 
D8  Usad to 
Well 
Abandonment Status  Method 
D7 
Olher:"1 "-----, 
Estimate Well Yield 
Was the well property decommissioned 
0 
Air Lifting 
Final  Status 
Well 
D6 
with bentonile grout?  0  YES 
l!l  Balling 
Iii  Water Supply (in use) 0  in use  Abandoned Nol  O  D o.y 
ONO 
.. ,_ 
11 
0 
by  •-- •-c,,,.., 
0  Stand  (Back-up)  0  Deepened  YES, Indicate Date: 
Pumping Tat R«o,dJ 
D  D 
Observation  Other:-'"! =----,I  lr11,ufllcl•ritYleld 
Artuian condition, 
D 
y  y  y  y 
M 
M  0 
0 
F1  Well  Drawdown/Rec:cwery Water  DATA 
Level 
PUMPING  RECORD AND GROUNDWATER QUALITY TEST 
below 
(AJt  deplhs  g,ourrd,  clrcJe .,,,,,,,,,,,.,. unhs)  Orawdown  Recovery 
T.me  Waler  Time  Water LBW/ LB\181 
E1  Pumping Test ln1ormation 
(min)  (m/ft) 
RECOMMENDATIONS  /m/nJ  /-) 
Pumping Test  Date: Start 
O(SWL)  O(FWL) 
Recomm.  Depth: Pump 
1 
1120  1 
l<m®> 
YYYYMMOD 
2  2 
Static Waler Level (SWL): 
Aecomm. Pumping Rate: 
3  3 
!14  !(mi® 
ps  !<Lpsi@) 
4 
4 
Pump Intake Set at: 
If 
flowing, provide rate: 
5  5 
( 
'------' ml(!!) 
(lps/~) 
'-----~ 
10  10 
Duration  pumping: of 
15  15 
OhrsOmln 
20  20 
Final Water  (FWL) Level 
at end  25  25 
of Pumping Test: 
I  l<m@ 
30  30 
40  40 
G1  GROUNDWATER QUALITY 
Turbidity/Sand Content 
50  50 
Field Data 
Date Measurements Taken: 
60  60 
Slighdy turbid/cloudy 
Bacteria Testing 
YYYYMMOO 
Moderately 
D  D 
0  turbid/cloudy  Was a sample taken?  YES 
NO 
llyss, indicate the 
namt1 of the laboratory. 
Sample 
Date  Taken: 
0  Turbid/cloudy 
Eleclrical Conductivity: c:::=i us 
D 
Trace  sand present 
I~ ------'I ~I ___ ____. 
pH:  c:::=i 
YYYYMMDO 
0  No sand presenl 
T-ralure:  ·c 
c:::=i 
Water 
Chemical Analysis  of 
Well 
Groundwater  Disinfection 
Type 
Was a sample taken?  YES  indicate D  D  II yes, 
the 
NO 
Was  the  well disinfected  completion  the 
upon 
Date sample Taken:  name of  labotatory. 
Salty 
NO 
D  D 
of the pump inslallallon?  YES 
0  Odour Sulphur/ Egg 
~I 
-----~I ~I---~ 
YYYYMMDO 
0  Odour Organic Taste/ 
BrlBlfy  d8scribe  mt1/hod of well disinfection. 
0  Metallic Tasto 
Other:! 
WELL CONTRACTOR 
CONSULTANT  (If applicable) 
11  Company Name:  ,-------------,I 
H1  Name of Conlraclor / 
DriUlng  Company:fock Solid Exploration 
H2 Name 
ol Driller(s):erad Magnuson 
12 Company 
Address:  ~============all 
H3 Address of Driller: iip'iiocase=re;;c:'iWfi'ii:1if.te:ih;;ors=-e'"y;:;1F.a:i'oc':e?S============; 
Reference:  /===========,~I 
13 Report 
08  27 
14 Report Date:  I 
12019 
Signature of Primary Orile, 
YYYYMMDD 
Y  Y  Y  Y  D  0 M  M 
Date Submitted to D  Environment I.  Of 
Personal Information contained  thla fo,m  collected under the authority of the on  Is  Acc6ss to 
ADDITIONAL INSTRUCTIONS 
Upon  Water Resources Section COIT$letlng  ttu form,  (V-31 O), 
a 
lnlonnallon  (AT/PP)  and  be and Prolec;k,n of Privacy  Act, Section  compile 29  to (c)  wll  used 
please maM  or  lax  Department of Environment,  public database of  and ground  Information.  further  contact the 
tt  to: 
wel  waler  FOf  lnformaUon 
Government  Box 2703, of '11.Jkon 
of 
Manager  Resources  667-3223, Hydrology,  Wat8f  at  (867)  toll  free  wtthln'1'\Jkon 
Whitehorse,  Canada  A 2C6 
'v\Jkon,  Y1 
1·800-661-0408  3223. Ext 
free 
Please  feel  to contact us  at: 
I haw ,ud the •bow dlUN •nd 
Phooe: (867) 667-3171,  free  661-ooJS, local 3171) Toll  On 'YIJl<on):  (H!OO) 
undetslanddw-/or 
Fax:  (867)  667•3195  E-mail: Water.ResourcesOgov.yk.ca 
collection of ~rsoMI ln'omYtlon.  Signature of 
WeU  Owner