Well Record Page 1  2 of 
\{.kon 
WATER WELL 
Government 
DRILLERS FORM 
Well ID: 
Department  Environment of 
Water  Section ReaourcH  V-310 
YukonwatarWtll Registry  To  be  assigned  Dept. Of Environment by 
Metric  Q  Imperial 
Box 2703 WhitehOl'H, Yukon Y1A  2CI 
INSTRUCTIONS FOR COMPLETING THE FORM  4.  Please print clearly In blue or black ink. 
5. 
1.  2. Additional information  provided at the bottom  this form  Completion and submission of this form  the responsibility of 
is  is 
of  on  page 
the 
2.  867 667-3171. Question  directed to Water Resources at  drilling contractor. 
can  be 
6. 
3.  0.3 All well construction measurements shall  reported to  m or  Please specify metric or imperial units for all measurements. 
be  0.1  ft. 
WELL LOCATION AND OWNER'S INFORMATION  Well Name: A1  '--------' Optional  (I .e . City Well  No. 2) 
Company  I Department/ OrganlzaUon 
First Name 
ijName 
L
A2 Drilled For:  I Whj \e,  B,ve.C 
11  Pi c~\tl..£00 
A3 Street Address  Well Location: of  I \.-\P,.,5,f  :\\  3':¼  o,.1\d  '.?,5 
In sketch, Indicate distances from property line, 
septic field, fuel tank(s) and building. 
Please ':  ~ North arrow. de 
A4 Town  /VIiiage I  I Area  Loud ~e ape f  (,eee.\< 
A5 UTM Coordlnat~s (using handheld GPS):  !I. Zone  c=i 
A~ ~ 
I \L\0°  5:0, 324 w 
Easting 
of 
ofTop  I  ! 
a~ Cf  0 
A6 Elevation  Casing: 
mlftASL 
A7 Accuracy  GPS: 
of  !...._5 =-0=-- _____ __.!  +/- m €) 
0  WE'.\\ 
of 
AB  Purpose  Wells 
tt~-'--..J....-, ~ --------' 
IY15omestic  Test Well  Irrigation 
D  D 
D 
D  D Commercial  Municipal  Observation - Water Level 
,, 
D 
Industrial  Agricultt.lral  Public/Recreational 
D  D 
.  "\ 
LOG OF OVERBURDEN AND BEDROCK MATERIALS (All  are below ground  circle appropriate units, use descriptors prov/dad) depths  surface, 
'traed• <10% (I.e.  trace SILT  gravo/) 
"some• 10-20% (I.e.  SAND some grawl) 
(brown, QJWY- (IIHt1.  black,  CLAY,  SILT,  SANO,  GRAVEL ,  I  I  I  I satutat&d •a1tty  undy  grave¥ 2o-30" {I.e.  silty SANO}  MOISTIJRE: dry  moist  (wet} 
EXAMPLE 
retbh,  ~- ollw, ye/lowWI}  "and COBBLES, BOULDERS, BEDROCK  HARDNESS:  I  I 
sarwr or"and graver 35-50%  son  hard  hard 11'81}' 
ONLY 
brown  j j  SANO  I~! =::::::tra::•:•~•:'":ve::l:::::oo=:me::::•l::lt==:I  ::I ::::::::':°":::'":d:":"':'"::'":d:::::::::: 
88  87  Description 
B5  Common Material  Secondary Materials  Genenil 
Most 
B4 General Colour 
If  yes,  Indicated  depth  ft): from: c::::J  c::::J to: 
I 
( m 
BB  Permafrost Encountered: 
0 
Example: 
/Conum1 .. on Par,, ZJ 
WELL CONSTRUCTION 
I 
I 2  l 
DateWell  .lo t  '9  2..J 
20050131 
Completed  YMMD  D 
y  y  y 
C2We11Type:  O,whal-maleriol•Ol• 
C1  Drllllng Method  iii(;; Rotary  (Conventional)  Dug  Other  {please specify) 
D  D 
;:,, producing zone  localed? 
·  er 
Cable Tool 
0 
Rotary 
D Reverse  Air 
1  1 
06VEABUAOEN  BEDROCK 
D 
I 
Auger  (Hollow  Solid  Stem) 
0  Mud  Rotary 
C7  Comments Regarding Casing: Olher 
Casing  (dtJplh  befow  surface, p/sase circle appropriate units} ground 
C3 Outside  Casing  .C4  Ca~Matarlal  CS  Wall  Thlc kneH 
Diameter  /  ) cm  cm In  g'stHI  ,(n";") 
c::::J (  c::::J  ( 
C6  Ci-:· ~ ~ ~~ I  I 
I  0Plu1~  V 
6 
0  OOler  :::::::::J 
YG{5S02}F2  Rev.  0912008  '-t





Well  Record  Page  2  2 of 
WELL  CONSTRUCTION  /Conttnwd from P•g• 11 
Surface  / Environmental  Seal  (depth  bel ow  o s , p la gr und  urla ce lease circle  appro prla units) 
C9  Diameter  Seal:  Seal Depth from: of  C10 
ca s111  Material  Seal Depth to: Type:  C11  _C) 
,_.,.., ___ _.(cm €)>  ,_ _____ _.
( m/ lt ) 
~) 
I 
lim~ 
l \)t ~yTl I 
'..:eentonlte) 
1/0.., 
tlo 
0 
\0 
Gravel  Pack  /depth  below ground s ,  se ul1aco plea c/n:/o appropriate  Ulll } ts 1 
5-rQve\ 
Gravel  Pick:  6).J)IQ- II yes,  Indicated depth ( m I 
_1-t__ 
C13 
Material type: 
j2rYES  from:  to:  lndlcatedlameter ofmatetl : 
al c::J0 ) 11nchos
I 
.slllca l.e
appropriate  } 
Well  Screen  lnfonnatlon  /depth  below ground sutface,  please clrr:t•  units Depth  Depth from:  Slot C18  to :  Size/  : 
Perforation  Dia
C17 
Screen1,! \l(p  Hm @I , IP i( n@(E] Thou.tmmllnchos 
C140utsldt  C15Sc~ C16Scl'l!Jl.fype  Screen2.j 
aterfal  !(m/ft)  j  !(m/ft)  c=JThou.tmm/inchos 
Dlam.ter  (cm/ In) IB'Stalnless Steel  ontlnuous Wlte 
[B"'l; Wrap  ::====:  r---, 
I 
r----7  D  D  Louver  Screen  3.  !( m  I  ) !  ! ( m/ft ) ft  L___.J Thou./ mm  /Inches 
Steel  ·  Screen 
D  D 
,.;=-r- Perforated 
Plastic 
B 
O  2-- ~~er::::::::B ~~::~ole  ClS~~::'ents: 1--------------------, 
WELL  DEVELOPMENT  AND  STATUS 
05 
Well 
Yield  Estimate 
D1  Well  Developed  by  D2 Well  Head  Completion 
03  04 Well  Head  Stick-up  Static  Water Level 
!il,trge  Block  House D Well  (•bovegroundautfac.~ C)  (bmwtopotculng}  "7\ 
!(Lpst€l) 
I 
~ , tar Jetting  Pltless Adaptor 
D 
~ad,ptor. 
I  H ~  I  Hm
\!!.v 
( 
I  L__J  m/ft ) 
40+ 
Jetting  Air Lifting 
USO  nogalive ff below  below rade}  ""9'!t'7  grade) 
( g (Us•  ff 
Belling  Pit  (NOT  PERMITTED) 
' 
u.  _  ~I  to" 
Pump (well not completed) lng--Qlqoi\e
. 08 
Mettlod  Used  to 
· I  07  Abandonment Status 
Well 
0ther:I  I  Wolf Yield 
Estimate 
well  property decommissioned 
Was the 
l1ktll.iftlng 
Well 
Status 
06 
Final 
YES 
with bentonlte  grout? 
D 
D 
Bailing 
D  D 
(In  use)  l!i:!'itoi  In  use  Water Supply  Abandoned  D o.., 
If YES, 
Date
D  D 
Stand by (Back-up)  Deepened  Indicate  : 
«-n- 0  Poorau y alil
Pumping Tut R«:Old) 
D  D 
Observation  Other:r-"'-~--.., 
lnsu ffic ientYleld 
0Artuianconditlons 
D 
.
YYY YMMD 
F1  Wolf  Level Drawdown/Recovery  DATA 
Water 
PUMPING TEST  RECORD  AND  GROUNDWATER QUALITY 
Orawdown  Recovery 
(AJJ  depths  ground,  c/n:/o  appropriate  units} 
below 
Time  Water  Water LBV91  T,me  LBVel 
E1  Pumping Test lnfonnatlon 
(min} 
(min} 
/min}  (m n} 
i
RECOMMENDATIONS 
Test  Date
Pumping  Start  : 
O(SWL)  O(FWL) 
Recomm.  Pump  Depth
: 
1  1 
I 
j1m,ft) 
Y  Y  Y  Y  M  M  D  _D 
2  2 
Static Water 
Level  (SWL): 
Recomm. 
Pumping  Rate
: 
3  3 
j 
!(Lps/gpm) 
I  I1m,ft) 
4 
4 
Pump  Intake Set at: 
If  i , prflow ng ovide  rate: 
5  5 
I 
!(m/ft) 
j( Lps/gpm) 
j 
10  10 
Duration of pumping: 
15 
15 
DhrsOmln 
20  20 
Level 
Final Water 
(FWL) 
25 
25 
at end of 
Pumping  Test: 
I 
!(m/ft) 
30 
30 
40  40 
G1  GROUNDWATER QUALITY 
Turbidity/Sand  Content 
50  50 
Flefd  Data 
Date  Measurements Taken
: 
60  60 
D 
Slightly turbid/cloudy 
Bacteria Testing 
D M,ode,ately  ld/c!oudy  _ a  j D  E ~ . llyes,Jnd/cafe 
tu.!)>
w_as  sample a~n?  '( .§._QNC! the 
Date  Sample Taken:  name  the  laboratory. 
of 
0  Turbld/ctoUdy 
Electr1cal Conductivity: 
c:::::::J  us 
Trace  sand  present 
D 
I  I ._I __ ___, 
: 
c:::::::J 
pH
YYYYMMDD 
D 
sand  present 
No 
:  C 
Temperature c:::::::J  • 
Water 
Chemical Analysis  of 
Well 
Dlslnfectlon 
Groundwater Type 
a  D 
sample 
Was 
taken?  DYES 
NO 
If yes,  Indicate 
the 
Was the  well disinfected  completion  : 
upon  Sample  Taken name  f/Je 
of 
laboratory. 
Date 
the  pump  YES  NO 
of  Installation?  D  D 
D 
Sulphur/  Odour Egg 
YYYYMMDD 
D 
Organic Taste/ Odour 
I~--~'~'--~ 
Briefly describe  method of well disinfection. 
Metallic 
Taste 
D 
D 
:! 
0111er
CONSULTANT  (If appl/cable) 
WELL  CONTRACTOR 
,------------, 
I 1  : 
Company  Name
Address:
12 
Company 
~============! 
Report  Reference:  :=· ==========,~ 
13 
Date
I 4 Report  : 
YYYYMMD 
D 
YYYYMM 
O 
Date  Submitted  to 
Personal  information contained  on this  fonn  Is  coUected  under the  the authority  Access to 
of 
ADDITIONAL  INSTRUCTIONS 
Upon completing this  form  Water  Resources  Section  (V 310), 
· used Information and Protection of Privacy (ATIPP)  Act,  Section  29  (c)  and  wta  be  to  compUe 
a 
pSease  mall  or fax it to:  Department of Environment
'  , 
the 
public  database  well  and  g-ound waler  Information.  For further Information  contact 
of 
Government of Yukon  Sm:  2703
, 
of 
Manager  Hydrology,  Water Resources at  (867)  667-3223 toU  free  within 'r\Jkon 
, 
,  Vt A 
Whitehorse, Yukon Canada  2C6 
1-800-681-0408 Ext 3223. 
: 
Please  feel  tree  to  contact  us at
haw fNd tht abovt  and dluu 
I 
Phone: (867)  667-3171, Toll  tree  (In \'IJkon):  (1-800)  661-0408 local  3171) 
, 
undentand  tor fJU1PON 
tht 
Fax:  (867)  E-mail Water.Resourc88 Ogov yk.ca 
667-3195 
:  .
colle4tlon  lnlanmtion. 
of  ,»rsanal 
Signature  Well 
Owner 
of