Well Record Page 1  2 of 
\(.kon 
WATER WELL 
Government 
DRILLERS FORM 
Well ID: 
Oepllrtment of Envltonment 
Watlr Resources Bection V--310 
be  by Dept Of 
VukonWaterW.11 Regl1try  To  assigned  .  Environment 
Metric  O  0 Imperial 
Box 2703  , Yukon Y1A 2C8 Whftilhoru
4. Please print clearly in blue or black ink. 
INSTRUCTIONS FOR COMPLETING  FORM THE 
5. Completion  submission of this form is the responsibility of and 
1.  2. on 
Additional information is provided at the bottom of this form  page 
the drilling contractor. 
Question can be directed to Water Resources at 867 667-3171. 
2. 
Please specify metric or imperial units for all measurements. 
6. 
3. All well construction measurements shall be reported  0.1 m or 0.3 to  ft . 
1  Ll ______ _.!  Optional (i.e. City  2) WeU  No. 
A  Well Name: 
WELL LOCATION AND OWNER'S INFORMATION 
I Department/ Organization 
First  Cofll)a.ny 
Name  Last Name 
A2  Drilled For:  ~IM_ia ________ _.!  l"""'L._a_m_ba_ult _____ ___.  ,.._ ______________ _. 
88 Drumlin 
Sketch  Well of  Location 
A3 Street Address of Well  Location: 1
I 
In  from  line, sketch, Indicate cf'tstances  property 
septic fleld,  fuel  tank(s) .and  bl.aiding. 
111
Please include  arrow. 
North 
A4 Town /VIiiage /Area/ Lot IJ:  l •Meh  orse Copper 
I 
. 
A5 
UTM  Coordinates (using handheld 
GPS): 
NAoITTI:Jzone[=:l 
q, 
v-nv'  '"'l,ON't 
I 
Easting 
Northing 
of  of 
A6 Elevation  Top  Casing: ~I __ 
! m.(jj)ASL 
4qq:n =t 
e: 
A7  of 
Accuracy  GPS: rs 
tJ 
I +/-ml® 
~-----
\p  -=n  ' <b  c;-"l 
AB  Purpose  Wells 
of 
-
vmncmmr \ctOdllljj 
Ii Domestic  D Test Well 
D Irrigation 
E~ 
Commercial  Municipal  Other (please identify use) 
D  D  D  D 
- Level Observation  Water 
Industrial  O Agricultural  D Public/Recreational 
LOG OF OVERBURDEN AND BEDROCK MATERIALS /All dBplhs  surface,  appropriate units,  descriptors provided) ""' below ground  cirr:Je  US8 
1n1ce•  .  ._ <'1°"  SILT (1  in.:. fl/'lMll) 
.
•~•10-"'°"(l.• SAND«11Mgraw/) 
_,..,.,,,.,,....,..,.,...,.p ... a/ll)'SAJID) 
EXAMPLE  (blown. gray.  green, back,  CLAY,  SILT,  SAND,  MOISTURE:  I  I 
GRAVEL, 
O)'  moJst  aturalad (W«} 
•MMJ Sllnd"or-ar,d grawf" 35-50% 
HARONESS:solllhMd/wr,yfwd 
--OM, -I  C0681.ES,  BEDROCK BOUWERS, 
ONLY 
soft and saturated 
trace aravel  somes
iH 
11 
- II  SANO  II 
General 
84  87 
General Colour  Description 
B5 Moat Common Material  86 Secondary Material• 
clay 
brown  silt 
1Jtae1<grey 
"""'""" 
BB  Permafrost Encountered: 
0  NO  II  yea,  Indicated  depth  ,®: from: C=:J  C=:J to: 
( m 
Example, 
WELL CONSTRUCTION /con-. on"'"° ZJ  Date  pc19 Well  09  21 
20050131 
Completed  ~-----------' 
YYYYMMDD 
D  D 
C1  Drllllng Method  Air Rotary (Conventional)  Dug 
D 
Other  (p/aast1 specify) 
C2 Well Type:  :_:-,:.=-i :.:::::• 
! 
I! Rew,rse Air Rotary  Cable Tool  l 
D 
D  D 
OVERBUAOEN  BEDROCK 
Mud 
Rotary  Auger (Hollow/ Solid Stem) 
D  D 
Casing  /dep/h  below (J«JUlld  .,,,,.,,,,, p/HH cJ,r;je appmptlat•  un1,-J 
CT  rher Comments Regarding Caalng: I 
C3  Titlcknooa Outside  Wall Cl Cnlng Mator1al  Cl CHlng 
Cl Ctalng D•rth to: 
Dlamotar~ (cm@)  1!161"'  ~(cm/€)  18  (m/0 
·-
Olh•r 
c::::::J 
YG(5302)F2  Aw. 0912006





WELL CONSTRUCTION  {Condnued fn,m P, .. 11  Well Record Page  2  2 of 
/  vound Surface  Environ mental Seal (depth  below  sudace,  please circle appropriale ..,lls) 
CS  Seal Material Tyre: 
C9  Diameter of Seal:  C10 Seal Depth from:  C11 Seal Depth to:  C12 Volume Placed: 
[08m  menfomte  . 
p  !(m,©  .__ ___ _.(m'@ 
pO  !(cm@)  !D  !(m,© 
(I.e. Bentonite) 
Gravel  Pack 1---•u""ce. p1eusdn:1e-,.1e units! 
C13Gravel  Pack:  0  NO  yes, Indicated depth ( 
11  m(il)): 
type: 
D  YES  from:  nvn c:::=:J  to:  c:::=:J  c:::=:J Indicate diameter of material:  Material 
(  I 1,0s) 
i.e.silica 
to: 
Well Screen lnfonnatlon /depth be/cw gmund  _  • ,..-, ,,,....  _,., ...,. C17 Depth from:  Depth  Slze / Perforation Dia: c1a  Slot 
1 
Screen 1. I  I  ( m@ r:::=J Im@ c:::=I Thou./ mm Ii,€>• 
C140utslde  C15ScreenMaterial  C18ScreeConnTytinpeuousWireWrapScreen2.!  !(m,©  !lm@c:::=IThou./rnm/;,@,s 
I 
Diameter  Stainless Steel 
D 
0
1  """) 
I  m@  r:::=J  c:::=I 
C=::J  cm"'"'  D  D Steel  Louw,r Screen  Screen  / 
3.  !(  m,©  Thou./ rnm  ;,@,s 
( 
Plastic  Perlorated 
D  D 
C19Screen 
0  O 
NIA  Slotted 
Comments:'------------------~ 
D  Other'"!  Open Hole ----,ID 
WELL DEVELOPMENT  STATUS AND 
D1  Well  D2 Well Head CompleUon  Well Yield Esdmate 
Developed by 
05 
D3 Well  Head  Stade Water Level Stic:k,up  04 
Surge Block 
0 
(abave91DU11dnmc.J  (l»lowtopolCMlnf} 
House 
!18+  !(Lpst@,) 
D Water Jetting 
l!l Pitless  Adaptor !]!e!!!.!:!. adapfo,: 
~cm.@  !36  !(m@ 
l!l  Air Jetting / Air Lifting 
L..J<m@ 
(UH nc,ga""'  I/ below  below gn,de)  gn,de) (IJ,e nc,ga""' N 
D 
Bailing 
Pit (NOT PERMITTED) 
l!l  Pur!l)ing 
None (well not completed) 
D 
DB  Method  Used lo 
D7 
Status 
Well Abandonment 
Other:,.!~--, 
D 
Esdmate Well Yield 
Was 
the well properly decommissioned 
D 
Airlifting 
06 Rnal  Status 
Well 
YES 
D 
with bentonlte grout? 
D 
Balling 
D  D  D 
Water Supply  use)  Not in use  Abandoned On  o.y 
ONO 
If  Indicate Date: YES, 
Stand  (Back•up)  Deepe_;-ncced=-----, by  """- D ._au,0y 
D  D 
D~~t-· 
Put'J'fl(/T..tR«otd) 
I 
OMNlancondtlon• 
YYYYMMOD 
Well 
F1  Waler  Drawdown/Recovery Level  DATA 
PUMPING TEST  RECORD  AND  GROUNDI/\IATER  QUALITY 
Drawdown  Recovery 
(All-belawgn,untJ, dn:Je-,.reun/fsJ 
Tme  Water leval  Time  Wat8f ll11191 
E1  Pumping Test Information 
(min)  (m/ft)  fminJ  (mitt) 
RECOMMENDATIONS 
Pu"!?i Date: ng Test  Start 
0(SWL)  0(FWL) 
Recomm. Pump Depth: 
1  1 
~---~(m@) 
YYYYMMDD 
2  2 
Static Water Lew,i (SWL): 
Recomm. Pumping  Aate: 
3  3 
._ ____ _,(Lps/@) 
~---~(mt® 
4  4 
Pump Intake  at: Set 
If flowing, provide rate: 
5  5 
I  !(m@ 
I 
!(Lpstdii1, 
i 
10  10 
Duration  pumping: of 
15 
15 
DhrsDmin 
20  20 
Final Water 
UMl! (FWL) 
at end of Pu"l)ing Test: 
25  25 
'-----~( m,@ 
30  30 
G1  GROUNDWATER  QUALITY  40 
40 
Turbidity/Sand Conten1 
AeldDat.o 
50 
50 
Date Measurements Taken: 
60 
60 
Slightly turbid/cloudy 
D 
Bacteria Testing 
YYYYMMDD 
D 
Moderately turbid/cloudy  sample taken?  YES  NO  lhe D  D  ff yes. incfcate 
Was 
a 
Date  Sample Taken:  name ol lhe laborator)l 
Eleclrlcal Conductivity:  c:::=:J  uS 
sand  present 
I 
pH:  c:::=:J 
YYYYMMOD 
No  sand  present 
D 
c:::=:J 
Temperature: 
•c 
Chemical  Analysis  of water 
Well 
Groundwater  Disinfection 
Type 
a sample token?  NO 
YES 
0  O 
Was 
ff 
yes,  indicate lhe 
Was the  disinfected upon cor!l)lellon well 
Sahy 
D 
name of the labotatory. 
Date  Sample 
Taken: 
of  pump 
YES 
the  lnstaUalion?  NO 
D 
Sulphur/  Odour Egg 
._,1 ~-,-,----,-,-----JI  ._I---~ 
YYYYMMOO 
Organic Taste/ Odour 
D 
Brl«ly dsscrib6 method of wolf dlslnf8cllon. 
D 
MelallicTaste 
Olher:r! ----, 
D 
WELL  CONTRACTOR 
CONSULTANT/// app/lcab/e/ 
11  Company Name:  .-------------,I 
H1  Name  Contractor/  Cor!l)any: of  DriUing  eock Sohd  ExploraUon 
of 
H2  Drillor(a): Name  Magnuson 
Cor!l)Sny Address:  l=============ll 
12 
H3  of Driller: Address  ip'ii'o'iisi:!era~c';;W,i'ciffEe'rho;;;rae='.;y;;uki:':o"'n===========l 
13 Report Reference:  l==========:,~I 
14  Date: 
I 
Report 
Signature  of  Primary Drller 
YYYYMMOO 
YYYYMMDO 
Date Submtted to  De  I.  Of Environment 
ADDITIONAL  INSTRUCTIONS  Perscnal  lnlormallon conlalned  on  thl5 lonn  ol  Aocess Is colleclod  under the  the authority  to 
e 
Upon coq,leUng ttu form  Water  Reeourcea  Section  (V-310),  Information and Protection ot Privacy (ATfPPJ  Act,  SecUon  28  (c)  and  will  be used  compile 
to 
pluae mall  or  lax It to:  '  0ep.rtment of En\1ronmenl,  publlc  databaae of  wel and  c,ound water  lnlormatlon.  For further  lntonnatlon contact the 
GOYernment of"-'kon Box 2703,  Manager of  Hydrology,  Wale,  Resource& at  (86n 667-3223,  toll free  within "-'kon 
Whitehorse, 'i\Jkon,  Canada Y1A 2C6  1·800-681-0408 Ext  3223. 
Please feel  free  to  contact us at: 
I  claUN hlW tNd  abow  and 
the 
Phone:  667-3171, Toi free  On"-'kotl): (1-800)  661-0408, 
1oca13171) 
(86n 
undetsllnd  purpoH for 
the 
(66n 
Fax:  667-3195 E-mal:Waler.RasourcesOgov.yk.ca 
coUKllon at,,.,.,,,,., id'onnldcn. 
of 
Signature  Wei  Owner