Well Record Page 1  2 of 
\(.kon 
WATER WELL 
Govemmen1 
Department of Erwlronment 
Well ID: 
DRILLERS FORM 
WawrRHourc.s S.CUonV•310 
YukonWattrW.n Registry 
To  assigned  En..-ironmenl be  by Dept Of 
Box  WhltehOtH,  2C8 2703  'Y'ukon Y1A 
Metric  Imperial O  0 
INSTRUCTIONS  COMPLETING  FORM FOR  THE 
4, Please print clea~y in blue  black ink. o, 
1.  Additional Information is provided  the bottom of this form on page 2. at 
of  of 
5. Completion and submission  this form is the responsibilily 
867 
2. Question can be directed to Water Resources at  667-3171. 
the drilling contractor. 
3. All  construction measurements shall  reported to  m or 0.3 
weH  be  0.1  ft. 
6. Please specify metric or imperial units for  measuremenls. an 
WELL LOCATION  OWNER'S INFORMATION ANO 
1  ._!--""'--=----'' Optional  (i.e.  ty Well  No.  2) 
Ci
A  Well Name:
Firsl Name  Last Name  mzation ~ ./·company D:8P-arlt1te.nt I.  Orga
A2 Drilled For: 
..___E.= B:c..Y.__ __ ___,1 1 .... ---'--K -~e~~~"~--~I ._I ~-~~~-------J 
X  Ar ~1  0$-'.\C-'v'\  Sketch  Well Location of 
A3 S1reetAddress  Well Locailon:I of 
In  sicelch. lrnlcat• otstancas kom properly line. 
aepUc rteld.  lank(s) and luel  bullding~ 
Plose indude Notlh arrow. 
A4Town /Village/ Area/ Lot#: I ,- ' t-Jc;t,.  sin  L.::.t feg._ 
AS  UTM Coordinates {using handheld GPS):  NAO  Zone  ·c=i 
\J T M  1/4> 1\  t  <i, 
?  2.  qq t  2, 
EasUng  NOfthirig 
A6 Elevation ofTop of Casing:!._ ____ __,!  m .(jj)AsL 
tt113  ss~ 
of 
A7  Accuracy  +/-GPS t: - .~ ·  m ---------''-----~ I® 
of 
AS 
Purpose  Wells 
!iii  Domeslic  D Test Well 
D Irrigation  Envin,, .. --,"""'w,~ - ---------
D  D Commercial  Municipal 
D Observation - Water Level  Other 
idonti(plea~  fy~J 
0 
Industrial  Agricultural 
D  D 
D 
Public/Recreational 
.I  I 
LOG OF OVERBURDEN ANO BEDROCK MATERIALS (AH depths are below  surface. ckcle approprtat•  descrlplors providooJ ground  unHs,  use 
'tr.:.· ,do~,  {I.II  S11.1  ,~ IF....,, 
--som.,~,a-2tfflo(ia  SANo-,,,.~,, 
EXAMPLE 
_ . ,=...,,,;::1:.~~ C~~~~=CK •.aty;=~-=~::.:.:!1s::.~J  ~=~r;;~ 
_ 
ONLY 
_ 
11_ SAND  .::~)~'--:::- · ,,  , ~ ==--==,,..=="'==--==·=··==~r .. .., '.
111
-~  l  B4  Colour  Most Common Material  Sec:ond.,-y Materials  General Dflic:ripllon " \!!J  Gan11'111  B5  815  87 
12 f",_.,,  · o
BJ.T -:.·  ·1--------t 1---~-------t 1-=---~~~-=--t I---=--~~-~-----! 
6  Y t.(t?.  ··  c.,,,'(. ,,  C (" 
1-~~-">''----ll---~-"',:..;_-'-----ll------'-'--"-c-~-~-1---'=----------1 
:fE1.  ~~----l-~~,,_,_,/4-~--1 -~-~-'=,r;_,,_j::.::li"--~~'--.:..._-~~"'---'---!I--------~ 
i----=-- i-= .... .=.;;;..._'_....,....., .. p.----,---'-"""'"""'--.,......--1  ~~~--~"'--"'"'-='"""'·
:;._.;.,.,. · ;;.i··· 
~= ...:.....;;;;;;,....;_c.........;c;;;.;_.;_.;...:;---1 
~ -
....  --· 
If  yes,  Indicated  depth  1€\: Som: c:::::J:  .,,c::::J· 
( m 
D 
BS  Permafrost Encountered: 
NO  Oves 
E_,,., 
DateWeH 
WELL CONSTRUCTION  ,c.,,unue• on P•P 11 
2005 Of 3f 
Completed  ·v . v  v  v  M  M·  0 
..  .. 
0 
A; R;tary C1  DrtlUng Method  ii  (ConvanUonaO 
Qci;,g  QOUlflr(ph,i,se~ 
C2 Well Type: :.:-~;:=-f• 
.  1
Cable  Tool  I'  -- . ..  ...
0  Reveroe  Air  Rotary 
)!:l OY6'BUROEN  eEo,,oct( 
Rotary  (Hollow/ 0Mud  Auge,  Soid Stem) 
D 
Casing  ,....,,a,;.,,..,,..wJ...,,.,,•.p/NHm:•-.,,,l.,.unilsJ 
C30utolde  C4CalngMat•~•t  C5laWWillThlctu1asa  C&C~ to: 
. 
DlameterL-;1--J (cm@)  ISSt•al  (cm/€) 
L..1ad!l4  10 
m 
tJPta511c: 
C 
otou  t(::::::::; 
Y0(53-)2tf2 An M/2006 
,





Well Record Page 2  2 of 
WELL  CONSTRUCTION  (Conllnu,d ,...., P, .. I/ 
Surface/ Environmental Seal  (dnpl.h  appropriale unilsJ beklw or::iund  surface, please circle 
C11  Seal Depth to:  C12Yolume Placed: 
ca Seal Material  Diameter  Seal:  Seal  from: Type:  C9  of  C10  Daptb 
j  .  ltm@  · im·._ _____  ,© 
jBent ,le on j  ______ 1,.m,@)  ______ 1m,® 
(i.c,&t-1k1nilo) 
Gravel Pack {depth  drcte ~~1)(,:,P'"3te bo-lcw fl{OOffd .surlac c.  please  urntsJ 
C13 Gra'Vel Pack:  'II  depth ( m 0  NO  y&l; lndlcalM  .@}: 
0 
YES  trom:  c=-J ,  ( to:  c=-J Indicate diameter al material: 
c=-J mm 11,€):s) 
Well  Screen lnformatlon /dcpfhb<.i,wgcoondsun.co,p18;sed,c,._op,ia,...,IS)  ~m:©-- ~TPerforotlo,•~.'. 
© 
Screen1,~lm II  L....=z,L.Z._.J(m  n  L-...t:l--1  hou.lrmi  11~ 
c1•0U1S!de  C15ScroenMaterial  C16ScreenTypo  Scroen2.rtnz---l1m(ii) ~tm.@ ~ _ noou.1mm11,@,s 
Olametor  l:i,.St:tinles.s Sleet  Contir.uous Wire Wrap O  l-..f-,4J---J 
11
11
CCJ (cml@I)  0  D. -Steel  Louver  Screen  $Green  1..c=::Jcm@ C==tt m,© · ./ "c::J1tio~ '"!  rG-~ 
O  O PfaSlic  Pertoraled  CIS 
5 
D 
NIA  ,----, a Slohed  creen 
In  Open  Hole  Common1s:  L------------------"' 
'()!not! 
D 
WELL  DEVELOPMENT  AND  STATUS 
D5  Well Yield Estimate 
D1  Well  Developed  by  D2 Well  Head  Completion 
OSu,ge81cci< 
OW.UH0\1$&  c::::i:z:J ( 1.ps 1 @,) 
i
D 
Water  Jen ng 
Adapto,  ~inD!i1r: 
I 
[!l Art Jetting  Air Ufling 
L_J1n\,©
.  · 
DsaK;ng 
0  Well  P.
pa (NOT  ER!,,IITTeOJ 
0Puinf>it31 
D None  (Ytell 1191  CCffl)lelad) 
08 Method Used to 
D7 Well Abandonmen1 Status 
Dotller=,...-.---~ 
Estimate  Yield w.n 
'---~ 
Was  lhe  ~II properly decommissioned 
0 
AirLift,_
ng 
Well 
D6  final  Status 
bentonlte groul7 with  B 
0Bailiffg 
D  D  D Water  Supply  use (in  use)  Not  in  Abandoned  o,., 
:  YES; · , 
II  lricllt:a!a Oale
Stand by (Batk•up)  Dee~"i-ne"'d'---,  11,ff/!"'a'  1<>:)<tav.ibiy 
0  0  0 
PlltnprtgT•-,R«t,,dJ 
D 
Observation 
D  D  Ottler;I  I =~':7_!·•,_  '"""~:'II Y 1 •!d 
0Ar11nianc::i1•dl...,rc, 
M  O  D 
V  V  V  V  M 
F1  W.U Water LO¥ol  DrawdownlROCOYII}'  DATA 
PUMPING TEST  AND  QUALITY RECORD  GROUNDWATER 
Orawdown  Recovery 
(NI depfhs bttlow (}10/Jnd.  circ:t. app,opriatB IX'lif$} 
TJme  Walat  Level Ll!Vef  rime  WalN 
E1  Pumping Tat lnformatk>n 
{irtl flffffl1] .'  (ml "-1  min -J 
~( i 
RECOMMENDATIONS 
~9 Test SlarLOale:  _ 
,._ 
0 (SWL)  0 (FWL) 
Aecomm. PumpDeplh, 
I 
I  fim@i 
·y  y· 
Y  0 
2 
Sta_ _ lic Wale< Level (SWL), 
Reeorrm..Pumping  Rata: 
3 
·  1
· um1®  .._ ___ ~{Lpsl@t) 
Pump lt1lake set at 
• 
, 
.II  llow'"'!i provide  rale, 
. 
.._ ___ __, _! _ m '®J  s 
5 
!  J(Lpstoo),) 
10  10 
OuraUon  ol pumping: 
15 
15 
CJhrsLJmin 
20 
20 
Water Level (FWl.) Anal 
at  of Pump g 
eod  in Test. 
25  25 
I  -l<m'®  30 
30 
40 
40 
G1GROUNDWATERQUAIJTY 
Turt,ldltylS1nd Content 
·so 
Field  Data 
50 
0... -:r-., 
60 
60 
0 
Sighlly lurbld/cloudy 
Bacteria Tfttlng  -
YYYYMMOO 
a  NO Moderately turbid/cloudy  sample  lal<en?  D  D YES 
Was 
0 
lfyes. lno'icatelhe 
name of lhe laboratory. 
Dale  : 
SamplG'Tak en
E'8ctrk:al  COnductivilf.  (=::J us 
D 
T,ace  sand  p,esent 
I~ -,-----__,11 .._ ___ _,I 
, 
pH c::::i 
' y 
V  . V  Y  M  M  O  D 
No sand  present 
0 
Temperaturo: c:J. ·c 
Chemical  Analysis of Water 
Well 
Dltlnleotlon 
Groundw1IerType 
a  Ina/cars 
Was 
D 
taken?  DYES  NO  II yes,  Ille 
sample 
Os.tty  Was  the well  disinfected  completion upon 
Date  sii.rnplo Taken name of the laboratory. 
, . 
of  lhe pump insta lloo? la O  O YES  NO 
Sulphur/ Egg  Odour 
0 
___ 
I.___ ...  ---,- --· _ 
-- ___,II._  __, 
YYVVMMOO 
Odour 
Organic  Taste 
0  I 
y 
Brli,/l @scribe method of  . well dlslnfBc#on
MetallcTasle 
D 
D  Other: 
WELL  CONTRACTOR 
CONSULTANT  (If ,ppHcabkl) 
I 1 Company 
, 
Name ,----~------, 
H2 Nama  01  Oriler(,), 
pny 
12  company Addresa; 
__  ~l=-====a;a;a=====II 
ol Driller: 
H3  Addre<s  F.1~01~13i7'!:=='ilEE'Ri~;1a:;hc:"'58:::'!i-- "1, yr:is;'; _ . 
'f:l;1FlA":'., 2Z~1===-===I 
· _ 
;:-· - ·===============t---"'· :.,
I 3 Repo,I Aelsrence: 
: 
14  Report  Dale
y  y  y  y 
VYYYMMDD 
.o· 
M  0-
i,.
il!•  bfnlttod  •.  f)tf.~r~ni 
O S  10· 
AODITIONAL  INSTRUCTIONS. 
ParsOOaJ  lllforinati'on  contained  01r 1tiis•  ·co 'lomfli  uectiid Uf\da, the  authottty  OI  iii. Access lo 
·
upon comple g  ,  6cclion  -J I 
liu this k>fm Wilat Aa&otwcM  (V OJ, 
lnlonn.tfiol1  P Pt  >  29 •n.:I  rOlfJc/lQtl  ol  Nacy (A.TIPP Act. Sectk>n  (cl  be used  compile and  to ~i&I  ,a 
pleuo md 01 la-.:  it to:  ol Envitonnient, Dapariment 
puhjjc database of  ground  r,!om1attnn.  lnlormallon  Iha we~  and  w11te1  for 1u,n1er  conh1.ct 
Govoroment ol 'iUkcn  t"/03, Box 
Manal)ef  . Waler Ae.sootees  667·3223,  lree  'rukon of  Hydrology al (867)  loll  wilhln 
Whllt!hr1$E! Yukon.  IA 
,  Canada Y  2C6 
HS00·661-0408  3223. Ext 
Please leef ln!:e lo c.onlacl  : 
1ts  at
lhlwl'ffdht•OcwwdtuNMtd . 
Ptrnna:  867)  Tc,ll  lrP-e  J171J 
( 667•3171,  cinYukon): IHIOO) 661-0408, local 
undt,..tuad tM purpou ftK 
: 
f;u {861)  667  5  ·Walcr. s i 
•a 19 E-mat1 Ao1,.11,ucu gov.yk.c.i 
colltclion  lnfonNlion. 
ol per,on./ 
Slgnalu1e  Owner Well 
ol