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<lon<i•k;~~~ude  ~ -N 
AS  UTM Coordinates  handheld GPS): (using  NAD  [ill] Zone  c==i 
- - - ..  -
0 
!\'\'S l\,O<oSw 
Easting 
Northing 
A6 Elevation  Casing: ofTop of  I  ! 
I "i 4't 
m/ftASL 
ed 
A7 Accuracy  GPS: ~I _,~o~------'1 +t@tt 
of 
AB  Pui;pose of Wells 
·  Test Well 
D 
ul'tlomestic
D 
Irrigation  Environmental (Quality) 
D 
Commerc
D  D  D 
ial  Observation - Level Water  Other (please identi  use) 
Industrial  Agricultural  Public/Recreational 
D  D 
0 
LOG  OVERBURDEN AND BEDROCK MATERIALS OF  (All depths  ground surface, circle appropriate units, use descriptors provided) are below 
tmce· 
<10% (I.e.  trace SILT  grave() 
·some•  (I.e. SAND some 10-20%  gravel) 
I 
EXAMPLE  (brown.  sllty fJfBY.  gfHfl, blaek, 
CLAY. SILT,  SAND, GRAVEL,  "si s.andy  I graKt SAND)  MOfSTURE:dry I  I saturated lly  -¥ ZD-30%  (I.e.  moist  (wet) 
redsh, t»ige olfwt,  yetlowish)  "andsan<ror"andg,awr35--50% COBBLES,  BOULDERS, BEDROCK  HARDNESS:softl
hard/veryhard 
, 
ONLY 
brown  I I  SAND  j  ~I -~-=•~•~,..,~•~•-~"°~"'"=•~"•--~I  ~I ___ soft~~""~•~--=~.....,=---~ 
B7 General Description 
Most Common Material  B5  1M General  Secondary Materia
~•  ls 
Colour 
<o..., rJ  <,jl 
r,.  rlhl  soH 
h.u..a  In',  I 
r, 
,J 
\.,. .. ,1.-~,-ic" 
h ,,-dn. ·-
(\/(4. 
I 
o.'1--e.  ,J 
I 
I 
IJ 
' 
••, 
,. .. 
.: 
... 
-
:..  .: ·. - ~
',~iit 
' . .~ ' 
" 
· 
'~~
If yes, Indicated depth (m from [=:J  [=:J to
/ ft):  :  : 
BB  Permafrost Encountered: D NO  OvES 
WELL CONSTRUCTION  p- Date W~ O II  I~  a. -o  ()  (i,  ;}..  ,·;  Example, 
(ConUnue,on  2} 
r 
Complet~  ~L  ,  200501 ~1 
M  M 
v  v  Y  Y  o  o . 
D  D 
C1  Drilling  Well Method  Type:  • 
lli!"AJr Rotary (Conventional)  Other Dug  (please specify)  C2  ~:;,';'~~~•,,::::;::
Reverll8 Air Rotary  Cable Tool  L..------~  oveASUROEN  ~DROCK 
D  O 
Rotary  Auger  Solid Stem) 
Mud  (Hollow/ 
Casing (dt6pth below  surfacs,  appropriate uni ) 
ground  please circle  ts
C7  rh•r Comments Regarding Casing: I 
ce CIHlng  oerh th 
C3 Outside  Ca!)ng C4  Material  CS  !Hing ;j'I Thlckno
H 
( m \!!} 
Diameter~ (cm/In)  li!l"'s 1  l
i,e, (cm/ n) 
~ia . 
0 
Co  1  ° • :;:;r 
>
,.."'  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<m1•1 
I  I 'l("'1+ 
: .Bentonite) 
Boo 
10  0 
·s 
Gravel Pack (depth bftlowgroundsuriace, please circle appropriate units) 
C13 Gravel Pode:  [B'No 
If  depth ( yes,  indicated  m / 
ft  ): 
from:  to:  Indicate diameter  material:  mm/  Material c:::::::J  c:::::::J  c:::::::J of  (  Inches)  type: 
(i.e. silica) 
below 
Well Screen lnfonnatlon {depth  ground surfaCfl,  please circle appropriate units)  C17  Depth from:  Perforation C18  Size/  Ola: 
Depth to:  Slot 
Screen 1. c::=:::::::=J ( m/ft )  c::=:::::::=J (m/ft)  c:::::::::J Thou./ mm/ ;nct,e, 
C14 Outside  C15  Material  C16 Screen  Screen  Sere Type  .---------,  .---------,  ,--------, 
2 
Diameter  l  Stainless Steel  Continuous Wire Wrap  en  •  )  m  mm/ (cm/ In  D  L..,_______J (  m/ft  L...-....--..-J (  I fl)  L____J Thou./  Inches 
c=::J  B  B :i:!ic  ~~~ :reen  Screen 3.  m  m/ft) ft)  Thou./ mm,  Jnches 
c::=:::::::=J  c::=:::::::=J (  (  c:::::::::J 
I 
1
0 
C19 
NIA  Slotted .---~  Scrnn 
D  D Other  Comments: Open  Hole  '----------'---------' 
, , 
WELL DEVELOPMENT  STATUS AND 
05  Estimate 
01 Well  Developed  by 
02  04 Well Head Completion  Well Head Stick-up  Static water Level  Well Yield 
03 
0 
Surge Bicek  House  (•flov9,roumhurf•c•J  (b,lowtoporu,m,J 
Lps~ 
c::=:::::::=J ( 
Water Jetting  Pilless Adaptor 
D  D 
[!:!J!!!}..E!._,.,,  m {.) 
c::=:::::::=J  c::=:::::::=J (  ( 
5 
~r Jetting ~Air ~ifting 
Well  Pit (NOT  p~.,4;~i" )  (Use  ntflQSllve  ii belo~ds)  (U$e  negative if bslow grade) 
D 
None (well not completed)  Method Used 
'-1  D7  D8 
wan Ab"Jd~ment status 
to 
Other:j,.._ __ _ 
&ti mate Well Yield 
Was  the  well  properly  decommissioned 
~r,Lifting 
06 Final Well Status 
, \  ytllh bentonile groul?  B 
, ,  , 
Balling 
Water Supply  use)  Abandoned  /  \  \ (in  ii.l'Nol in  use  o,
D  D  D 
If YES,  Indicate Date: 
&~~~tcomple/e 
by  (Back-up)  Deepened  «-...  ,,_a,.,., 
D  D  D 
,Stand 
0
Putr.-,gTntR«ofd} 
= p1q5eD1ns~~Yl•kf 00ther:"'I =---~,  .-
I  1 ·, ' 
I  0.., ........ .,,,, 
YYVYMMDO 
F1  o~OWnlRecovery DATA 
Well Water Level 
PUMPINGTESY RECORD AND GROUNDWATER QUALITY 
Drawdown  Recove~ 
(Alf  gro~nd, circle appropriate units) 
depth$ below 
nme  water Level Water Level  T,me 
E1  Pumping Test lnfonnatlon 
(mini  (mlftl 
lmfn) 
(
mitt/ 
RECOMMENDATIONS 
Pumping Test Start Date: 
0(FWl) 
0(SWL) 
Recomm.  Pump  Depth: 
1  1 
'-----...J(m/ft) 
Y  Y  V  Y  M  M 
D  D 
2 
2 
Pumping  Rate: 
Recomm. 
Static Water  (SWL): Level 
3  3 
,_ ____ _,(milt) 
( 
'-----_J Lps 
/ gpm) 
4  4 
Pump Intake Set at: 
If flowing,  provide  rate: 
5  5 
._  _,( m/ft) 
____ 
'-------'( Lps/gpm) 
10  10 
Duration of pumping: 
15 
15 
LJhtsLJmln 
20  20 
Final Water Level (FWL) 
25 
25 
at end of Pumping Test: 
I·,  30  30 
I 
l<mtft) 
i 
J,  I 
I 
( 
40, 
l 
1 /IO 
G1  GROUNDWATER QUALITY 
\ 
50
50 
Turbidity/Sand Content 
Field Data 
60 
60 
Date  Measurements Taken: 
Slighlly tu/bid/cloudy 
D 
Bacteria Testing 
Was  taken?  D  D YES 
a sample  NO 
If  indicate yes,  the 
VYYYMMOD  Moderately lurbid/cloudy 
D 
of 
name  the laboratory. 
Date Sample Taken: 
.
Electrice/  uS Conductivity: C:::J 
sand present 
pH:  C:::J 
YYYYMMDD 
No sand present 
D 
C:::J 
Temperalure:  ·c  Chemical Analysis  Water 
of 
Well Disinfection 
sample  taken?  ~ES  D  If 
Was 
NO 
yes.  indicate the 
a 
Groundw,terType 
of 
Date  Sample 
name  laborstory. 
the 
Taken: 
Was  the  well  disinfected upon  completion 
0 ~
of 
lho  inslallalion? 
pump  YES  NO 
0 
!> 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<t  3223. 
Whhehofse, Yukon, panadaY1A 2C6 
lhawtNdttN~clMJHand 
..........,..,.,__,.,  ______________ ...J 
._ 
Please feel free  contact us at: lo 
Phone: (867) 667-3171, Toll  (In  (1-800) 661-0408,  3171) tree  :  local Yukon)
coUectionolp«Hll,lllnfotmatlon.  Slgnatureo!WellOwner 
Fax: (867) 667-3195 E-maU:Water.ResourcesOgov.yk.ca