Well Record Page 1  2 
of 
\(.kon 
WATER  WELL 
Ornia,r, ,n<trt 
01tpal1t1Hll'lt  En.,ol  lnmment 
Welll0 :. 
DRILLERS FORM 
~.,1er Rt- s ~ Soetion Y-our os  J10 
Y Well 1.1 ifon W-11111  R~lstry 
B x ZT Wt- t . 1> O)  tehorn Y•JJ<onY1A  ZC 6 
Metric  Q  lmpenal  ef 
INSTRU.CiTIONS F-OR COMPLETING THE FORM 
Ple e  riy  biur;  black •r,k :1s ~,,  ;!'H  c!e;:i Ill  or 
:  a1  ma t on  or a:  bu!!: ol 1 i, lor :n  p.age A.rJ:1iHo., 1:1TQ1  ,s  QVJdf,rJ  't .  2 he .m1  1s  011 
5,  tel!cP  S;;bmission of  res;mr.s: !ily Co 'Tlµ and  !1"1s  iorm ·a  ,e  hi
i
,11 
2 
O! tlon  direc!e R8M)u,:; a!  ·3 I  . ;es ~a1 1  :-le!  -:1  !O:Wate,  es  86 1 66/ 1? 
:.h&  d,illi,;g ,:,:,r1r3.-=:! 0( 
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wa1T~:ms On  ,easur sha ~  rep:>r!'3'Cf  :n  or it 
1  A(l  1 ruc!! .1 ;m1ents  00  !o O 1  i)  3 
O  · ri'-ll  for -l,I ~e.3.Se  s  3:>1,:2-m:;n(3 ,:;p:a:ity :rie 1~ic ~r  mpe ~P i! f"1~
WELL LOCATION  OWNER'S INFORMATION ANO 
,~ - ,-J · l l e. wen ; . 
A1  Well Name;:f __ - _- _ ._-' -''- "'_ '- --~~ oplion,111 C!t-,  -iC t, 
-
Lt.ii N .  ' 
a. ,~ Co~ari'i Dco.1 UJ1~f\t  •· ~Z<!t1.0i1 
1
A2 Drilled For:  .,,c  _ _  f''  _ ,..6.__ • · 
f'c:\,_.L._,_ __ __,il 
I 
l,.,,o  c "-,_.,__,._,"ce ,!\  11...-=--'---"'--""----'---"-'-'---'---'---,.--'J 
A3 Street  Well  \ 
Address of  Location:J  .... ~ Q11:  '\ : '::J \cA  f\;\"f,, '4:, .·~ .1 . 
Sketch  Well Location ol 
al Sllt!t: h  ! lJl'l.:O'. "1~15 -J ii :s  T/ :lr.lOC',
'y l;,19 
frt.,,
~:)(i,:-1,e!lJ.  H 
1!,91  l;/\;.(. :)(\j ·~ ;:hfl•J 
A4 
Town  Area I 
/Village I  Lot#: I  'I .  1 l;) t\@D' - -·C,;. tL 7, '. 
~H:S o!  ~, :.! iris N:>r1~-,  ~<'!.l\'f 
AS UTM  GPS); 
Coordinates (using handhold  ~NAD  }one . ; [::J
I  I __  v  e i"1'/I  "2-0 i-J  oi 
fasting  = •- ,,- g  -
~---,--,-- No- ,h,-; """ --,-----,' 
m , ASL 
A6 Elevation ofTop of Caslnli:\. -. _ 
1~  _,,,_,_,, _..,r  11 
t 
s::1  3 "1  lt  ci 
of  '---,.""-~----~ +I- I fl 
m 
A7 Accuracy  GPS:  ' 
(QwSlP'l,\t  5' 
N 
of 
AB  Purpose  Wells 
Domestic  Test Well 
0  O 
D 
Irrigation 
D 
E) rfvln:"""''"""1""'"'""r-------
D  D Commercial  Municipal 
D 
Observation -
Waler  level 
Other i l;p iJ:4se  deri ti! y<u
i ~ L 
0  D 
Industrial  Agricultural 
D 
Public/Recrealional 
1 ·  ·  ·  -
r 
EXAMPLE  -~~/!i!:iE?~~~~::;;~~~)1 
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84 Gc!rwral C0 1o u, 
'.  B&  Most C4mm0n M11t,1ri ;1II 
86 Secondary Ma1e,ials 
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e•,or~ At,  laty 
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Mu!1  Rota ry 
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, 
Reco of 
~ELL CONSTRUCTION  We!I  rd Page 2  2 
'.Co •,1t-,, ,u•1.f  ' '" 'IJ P:1 ; ,, 1.r 
Gravel Pack  o,, ( 'H>-.w ~- , ~,v , p J . • .Jt.'f' ·.,• ~ , •. ,t  •. .,., i _ ..- •:~  .J:.·-.:• • .. M •• ,.!O':.. IJ!n 
~c -
C13 Gravel Pack ·  0  NO  S  · ,11  i'l.'! 1ndicalcr:  :1emti (r•1  J '). !1
f ~ -
,  - ; I 
0  Yf:S  i ·  I  lr"'1'  !;:;i .c:;:::::::J  ri1;hc:1te  :,l,3rr~h1 .,. .T ~1e1!:'ll •. .c::::J;.  &\s:t,H  Ma e:tr:d  r;o::t.'. 
.  .  .  . .  _ ·- ·· .  Ja. -- iilt;3 J  .  _ 
WELL DEVELOPMENT ANO STATUS 
01 Wall Developed by 
W Head 02  all  ComphHion 
OSWellYie  •Estimate 
03 
Well Head Stick-up 
04 
Stat!(;  Water Level 
Su ge  131.x::k 
0  r
QW~IIHUl.1:te 
0  \Va.le.·  Jelling 
• ~- • 
Pille.;,.:- Adi'loto1  o.H: '!I  '·
D 
">" 
Air Je\tiflg , 
AU  L, fliog 
.. c::Jpn".• f, 
Pit  (N OH1ERMITfEDl
. 
I\IOf'e  ~we ll  ·
n61 com_p1etad) 
0 
08 Method Utad to 
15 ~ ,L .fr ,.,..,,c..,,--,,,  07Well Abandonment Status 
Well Y d 
Estimate  iel
t 
Was lhe wall  deCornm!S$!Qt'l2d properly 
O J\i,Littiog 
06 Final Well Statu~ 
wilt, Oeritoriite grout'  'fES 
0 
D  Boiling 
1
W-ale use; Not nu~  D ),; 
,O . r Supofy {i'fl _ o  AO:lnd0necl 
ONO 
D  l 
Pumoii ig Te.'i
0 
,EJ  sand~  Dcc~oed  __. ., 0  to  :> 
!3ac!(•uo1  '
· ,., ~ ,~ 
jl_ S Ql
YE; ;: l,:, ~':1.1.e  O.aw : ..  -' ·•·--· 
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·:.,;·--· • ·,;::,  --=i..o,,.,~·-·>.  ¥, 
F1 Well Water Level 0rawdownfRccovory DATA 
PUMPING TEST RECORD ANO GROUNDWATER QUALITY 
Drawoown  Aecove•y 
; 1 ,.,,~  ', .Jl,J"; ."~,t-,j/  T.:...., iJ  :':;;
}\'Ji" ~ 
E1  PornpingTest  Information 
1
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,  rm.: 
RECOMMENDATIONS  .-~,,.! " · -~· . 
~gn:rifng,Te.:;.LSa:r o
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20 
Final Wate FW'l
r Level t J 
end ol Pumping Tc-st
al  : 
25  ~5 
J  .t i~••t, 
30 
4Q 
G1  GROUNDWATER QUALITY  i!  40 
i
iurbidity Sand Content 
Field Data 
50 
·1 
so 
M ~mcm ken; 
Date  u,.; ur I.s  T3
60  60 
0 
1d
Si.ghtly tu:!) ::b<JiJy 
8actarl;a  THting 
Wds a :~amola taken?  YES 0  O  NO 
Mcd&at~ly ll11btn!clo ul.ly 
0 
,
if y!:';.  i
ndk;iU..=>  r• ,1 
Dale  lv Taken. S;imJ 1a1T"J~  t!lc' i;,t-.:: .-atmy 
,
0 
Turb f(jiduudy 
Elar.: c::::J 
tnca1 C0t1due11 v,ty· 
~s 
r T p;es
aci:?  .iand  f!m 
0 
y  ,  .,  "  "  ; ' 
'I  ,~  t ..  I  :·,1 ;i
0 
No sal\d pre:1erit 
Tco,o er a1::J  •  · - ·  j r. 
Chemical Analy$ls of Water 
Woll 
Ol&lnlection 
GrotJndwater Typw 
Was a s£tmple l ken?  NO  :a :tie ii DYES  1,  ,:.-; .n_ ,j1r..3
O  y, , 
1
0  Salty 
::nmpWas  the well -11s10Jcc1ad  upon  Oil.ie Taki;n. 
ia ti oi, 
~ .'tb-:J;a/Q''t 
·S&~ie:  3'7ltJ  J/ !I:
i ~ 
of l 11•:.tallotion., he 9ump  D  D YES  NO 
0 
Su! p : t1u1  :E gg  Cdt"lUt 
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Me1ak ufe 
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CO -! ~ g .
WELL CONTRACTOR  NSUt.TANT Jl ,:1 /c,;t,: . 
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• 
I 1 ComtinoJ  Na me.  r' "f.'"'"--,.,:;--,..,...,-.,..,,---..,,,.- /1 1 -.,-:,
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· ·NAL INSTRUCTIONS  - .  . 
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