RECEIVED JUL 1 3 2020 Well Record Page 1 2 of \(.lton Government V S B C~TER RESOUf CE RAN 't:, Department of Environment WelllD: I Water S.Ct:lonV..310 RHources YukonWaterW.11 Registry To be assigned Dept. Environment by Of VTtv\ '"2-01'.lt Box , YukonY1A 2703WhltahorH 2CI Me INSTRUCTIONS FOR COMPLETING THE FORM 4. Please print clearly in blue or black ~O\ "l Si f 1. Additional information is provided at the bottom of this form page on 2. 5. Completion and submission of this 2. 867 667-3171. Question can directed to Water Resources at be the drilling contractor. /. "=t lJ"\ ':) 3 N 3. 0.3 All well construction measurements shall reported to m or be 0.1 ft. Please specify metric or imperial u 6. '< WELL LOCATION AND OWNER'S INFORMATION A1Well Name: First Name Last Name Company Department / Organization I A2 \ _ ~ Drilled For: .._! 'o____,c..:.f'\i.:..:____ __,! FK-ru.fYlt,;;1'-e, k A3 Street Location Address ofWell M S ~ K d-e ;:2 on N Sketch Well Location of In sketch , lndlcale distances line, from property sep tic fieki, fuel tank~:dlng. A4 Town /Village/ Area/ Lot#: I L.c-f- \ \ OJ - 3 l ,.."' p ·~ c::::=:::J YG(5302)F2 R . 0912006 ... ' Well Record 2 2 Page of WELL CONSTRUCTION /Conunu•• P , hom .. t/ Surface Environmental Seal I (depth surface, approprlale units) below ground please circle C8 Seal Type: Material C9 of C10 C11 Seal Depth from: Seal: Diameter C12 Volume Placed: Seal Depth to: ._ ____ ...J(cm,€i) '-,-----'(m/ft) @'1 I I i ol,, .:ZS I I AL-S D Sulphur/ Odour Egg VYYYMMDD Briefly describe method of well disinfection. D O,ganic Tasle / Odour Metallic Taste D Other..-!----, D CONSULTANT (If appl~ica_bl_e.:,_) __________ WELL CONTRACTOR 1 11 Company Name: ' H1 Name of ConYactor / Drilling Ccmpany!M 0Rs• %hf s,, I\ 12 Company Address !=============ll H2NameofDriller(s):l;T'Hlt' A,.,,ie'-00' ' 13 Report Reference: /==========c--'I of H3 Address Driller: . Report Dalo: I 14 1..:::::: Z::: 1 .:io :2.. .:t 1o o o YVVYMMOD Signatureof Pr1maryDnller Y V Y Y M M D D Date Submitted Of Environment 10 De I. Personal Information contained this collecled under lhe authorlly on form Is the Access to of ADDITIONAL INSTRUCTIONS Information ProttldJon of a and Privacy (ATIPP) Act, Section will to 29 (c) and be used compile Upon complellng Water Resources Secllon this lonn, (V-310), public database ol and ground waler For furlher infonnatlon wel Information. contact Iha t ol Environment, please rnal or fax ii IO: De~ri, Manager Hydrology, Water Resources al loll within of (867) 667-3223, free Yukon GowrM18nl of 'Yukon 2703, Box 1-1300-661-0408 El