Well  Record  Page  1 of 2 
WATER  WELL 
i.lton 
Go\/emment 
DRILLERS  FORM 
Well  ID:\ .. __________ __. 
Depalt!Mnt of En"1ronmont 
W•"'' RH•""'"  S.C:tlon V-310 
To  be assigned  by  Dept. 01  Environment 
Metric  O  Imperial  @/ 
Yukon Wa"'r Wtll  Regiltry 
Box  2T03WllltahorM,YukonY1A 2C6 
Please  print  clearly  in  blue  or black  ink. 
4. 
INSTRUCTIONS  FOR  COMPLETING THE  FORM 
5. Completion  and  submission  of  of this  Jorm  Is  responsibility 
the 
1  . Additional  Information  is provided  at the  bottom  of  this  form  on  page  2. 
the  drilling  contractor. 
2. Question  can  be  directed  to  Water  Resources  at  867  667-3171. 
6.  Please  specify  metric  or  Imperial  units  for  all  measurements. 
to 
3.  0.1 m  0.3 
All  wall  construction  measurements  shall  be reported  or  ft. 
A  1 Well Name: !1-\.\c,..,\.c.~  ! Optional  (i.e.  City Wetl  No. 2) 
WELL  LOCATION  AND  OWNER'S  INFORMATION 
First Name 
""- &~ ~tt--
11  ~,  •  \-\4, \.!1A  t;,.,au '3 
A2  Drilled  For:  If c.s\11\ \ \ JJ\~ 
Sketch  of Well  Location 
A3  Address  Well Location: StrHt  of 
In  sketch.  indl , cale  dlslances  ll'Om  property  Mne
septic field.  tank(s)  . fuel  and  building
PleaSe  Include  North  arrow. 
A4 Town  /Village/ Area/ Lot#: I ..  f\11...., ________ .......1 
AS  UTM Coordinates (using handheld GPS):  NAO  [III] Zone  [=:J 
I  I  I r;ao  ~3:.'b1l  (,ot>  ,o.ssq 
(.i/~5,  Northing 
Elevation  Top  Casing: , 
A6  of  ... --,-l_'a ___ @ASL 
of 
A7  Accuracy  of GPS: ,_! _l._'?;...,.._ ____ --ll  +t@tt 
A8  Purpose  of Wells 
Environmental  (Quality) 
D 
Irrigation 
D  D  D 
~estic  Test Well 
D 
Other  (please  identi  use) 
D Observation  • Water  Level 
lii'eommercial  Municipal D 
D Public/Recreational 
Industrial  Agricultural 
D  D 
AND 
LOG  OF  OVERBURDEN  BEDROCK  MATERIALS  /All  provided) depths  are  below ground surface,  circle  appropriate  units,  use  descriptors 
· . trace· <10%  SILT trace (i.e gral/8/) 
•som11•t0-20'H,~.•  SAND"""8grave1) 
(!>"""1,  ,  /lfll'IO/y" g,e~  groen, blad< CLJIY.  SILT.  SAND.  GRAVEi. .  I  I  :  I  I "s,/ty  sandy  2Q-30%  sl!ty (i.e .  SAND)  MOISTURE dry  (wet) mo/sl  saturated 
EXAMPLE 
,  : l l
red/sh,  beige, o//;t,  )IOllowh}  COBBI.ES BOULDERS,  BEDROCK  __ •;;;;.•nd;;..sand'=..:or;.,;·•c;.cnd:..,g,:;.;;•.;.;;,.r;.,;35-:.;..;.;50""'--~  ~..;,HA;.;;R,;;;DN.;.:;E:;.;;SS'°'~soft;;;,;.;;hllrd=..;.;""'l';;.,..;.;hl~rrl'-~ 
ONLY 
brown  I  I !  SAND  ::,I ::::::_:_tr::.:ac:_•,..p:•av:_•::..l:::.=•:o_m:,,_•:..:•:ll_t _____ ~_.  ~===•o::ft:::an::d:::HIU:=r::oted=:==::: 
II  indicated  m / h ):  : 
yes .  (  : depth  ll'Om C:J  C:J to
88 Permafrost Encountered: 
Example : 
WELL  CONSTRUCTION  /Con//nuff on Pago 21 
200501 31 
C2 Well 
Type:  what geolOgical  rnaterill Is !he 
In 
0  Other (please  specify) 
'  ":;/J' proct.,c ng  zone  loeated? 
l
C1  Drilling Method  Air  Rotary  (Conventional)  Dug 
O  0 
[D,(\vEABUAOEN  BEDROCK 
ii<everse /1,jt  O  O 
Cable Tool 
Rotary 
I  I 
Auger  (Hollow/ Solid  Stem) 
0 
Rotary 
0  Mud 
Casing  /depth  blltow  , 
ground surface please c/Jc/e  appropriate units) 
CS  Cjslng  lo: Oerth 
C3  C5 Outside  I""'\ CA  Cas_Jpg-Material  Casing Wall Th~ss 
(m/ft) 
OiameterC::J (cm\!:!,V  [!"sl881  ~(cm~ 
1- ',_  Plastic---~ -r 
13{p'  5 q l( 
ou,er  ,_____. 
W 
YG(6302)F2  Re,, 
OW20()6





WELL CONSTRUCTION  /Continu,dftom p_.,.  11 
Well Record Page 2 of 2 
Surface /  Environmental Seal (deplh below ground  surface. please circle appropria1e uni1s) 
C8  C9 Seal Materta:~:  Saal  : Diameter of Seal:  C10  Depth from
C118ea1Depthto:  C12VolumePlaced: 
t  ~A"  os  .._-=-_  __.canG)f  1<-0 
I  lcmw  ...... _,,~--;;a--1<""'"'1 
(l.  .  ' "'""'•)  I  1  Q 
t:::Z  ,  Lf  M.3 
Gravel  \ 
Pack1<1ep1hbe/owg,r>un<1surfac,,, pteasecW'Cldepp,opr;,1e1H1;tsJ 
1 
C13 Gravel  yes, indicaled depth  :  -~  - . Pack;  0  NO  II  (m/ft) ;,  C.,.~~)(?,' 
lliH"Es  from:  to:  dicate diameter ol material:  (  Material type: mmG}  I 
I 
.  ~~-) 
Well Screen Information (depth below  surface, ground  please cm:te appropdate units/  C17 DepJh  C18  Perforation Dia: !:?ff'  Deplh to:  Slot Size/ 
Screen1, l\3V5'.i<m/ft) 1131'1 !<mitt)  ~mm/inches 
C14 Outside  C15  Material  C18 Screen  ~'Sl'nl'ype 
I 
m  m 
Screen 
I 
Diameter  (  Stainless Steel  Wire Wrap  2 • _.-L':ID  IB"Contlnuous  ;====~ (  ff  )  I  I  (  /II)  c::::=J Thou.  mm  /in<:hes 
I 
D 
C:=:J  Steel  Louver Screen  Scraen3.j  hm/H)  hmlft)  c::::=JThou./mm/inchet 
S  D  D Plastic  Perforated 
NIA  Slotted 
Other!  Open Hole In 
WELL DEVELOPMENT AND STATUS 
D1  Well  Developed by 
D2 Well  Heed Completion 
D4 
D3 Well  Level HHd Stick-up  Static water 
D5We11Yield Estl~ 
0  Surge Block 
House 
l•l>ow  fb•low ff'Ound •utf•c•)  top of cnlng} 
Q i,,ater Jetting 
1  le~ 
D 
PiUess Adaptor I°"""' j-' 
!<m@  Hmlft) 
I  I  _
iiTAir Jetting/ Air Lifting 
i
(m tt) 
40--t--
(Use negatill'e  grad&)  (Use  grade) if below  neQStlve  if below 
D 
Wen  (NOT PERMITTED) Pil 
.  Lt 
D None (well not completed) 
Well  Abandonment Status 
D7  D8 Method Uaod to 
B=r  , 
Eoijmate Well Yield 
Was the well property decommissioned 
06 Final Well Status 
~Lifting 
D 
with bentonlte grout?  YES 
D  D 
D 
Water Supply (in  use  Abandoned  Bailing 
use) ~n  o,y 
D 
ONO 
D -
D  D Stand  (Back-up)  Deepened by  ,..,..,  o .... 111y 
11  YES, lndicale Date: 
&~~ru:tcomplllflt 
50
D 
Observation  Other:-'") =----,I =:,:_.p1e.a Insufficient Yield 
D  D 
Pumping  T•st RIICOld} 
0Arteaia nccndllions 
M 
y  y  y  y 
D  D 
M 
PUMPING  RECORD AND GROUNDWATER QUALITY TEST 
F1  Well  Level Drawdown/Rec:ovory water  DATA 
(All-sbe/ow- clrc18llJJPIOJ)rlateun/rs) 
Drawdown  Recovery 
E1  Pumping THI Information 
Time  Water  Water Level level  T1m11 
RECOMMENDATIONS 
/min} 
Jm/h!  /m i
tt> 
/mmJ 
Pumping Test Start Date: 
0(SWL) 
Recomm.  Pump Depth:  0(FWL) 
._ ____ __,(  tt) 
m I 
1  1 
Y  Y  V  Y  M  M  D  0 
Static Water  (SWL): 
Level 
2  2 
Recomm. Pumping Rate: 
I  l<mlft) 
3  3 
I  !(Lps/gpm) 
4  4 
Pump  Set Intake  at 
If flowing,  provide rate: 
j(m,ft> 
I 
5  5 
!(Lps/gpm) 
j 
10  10 
Duration of P',lllping: 
15  15 
LJhrsC]min 
20  20 
Water Level (FWL) 
F,naJ 
of 
at end  Pumping Test: 
25 
25 
I 
1,m,ft) 
30  30 
G1  GROUNDWATER QUALITY 
40 
40 
Turbidity/Sand Content 
Field Data 
50  50 
Date Measurements  : 
Taken
60 
60 
D Slightly turbi~cloudy 
Bacteria Testing 
YYYYMMOO 
D 
NO 
Moderately turbld'cloudy  Was  sample taken?  YES a 
D  D 
If yes, indicats the 
name of 
the laboratory. 
Turbld'cloudy  Date Sample Taken: 
D 
Electrical Con<iJctivlty: 
c::::J uS 
......  ...... _____ __,I  ___ ___, 
1  1 
D 
Trace  present sand 
pH:  c::::J 
YVYYMMOO 
D 
No sand present 
Temperature: c::::J ·c 
Chemical Analysis of  Water 
Disinfection 
Groundwater Type  Well 
Was a sample taken?  YES 
D  D NO 
If yes.  indicate the 
Was the well disinfected upon completion 
name  o/ Iha  laboratory. 
Date Sample Taken: 
the pump installation?  YES  NO 
of  D  D 
Sulphur/ Egg Odour  .._I _____ _,I  I ..... ___ __, 
D 
YYYYMMDD 
Organic Taste / Odour 
D 
Briefly describe  well disinfection. 
method of 
D 
Metallic Taste 
D 
: 
Other r,----~ 
CONSULTANT (If appllc8bls) 
WELL CONTRACTOR 
~-------------, 
Company Name: 
11 
Company 
12  Address:~===-=========; 
13  Report Reference:  ~===========;--~ 
I 4 Report Date: 
YYYVMMDD 
YVYYMMOD 
Date Submhted  O  Environment 10  1.  Of 
Personal Information  form is  authorily contained on 1h11  colecled under the  ol lhe Acwu to 
ADDITIONAL INSTRUCTIONS Wat••  Section Resou,ces  (V-310), 
Information  Pn·w,cy (AT/PP)  Section  used  compile • 
and Protection  Act, ol  29 (C)  and wil be  10 
Upon completing  form,  Department of ~Is  EnvlroM1en1, 
public dalabase  well and ground water infonnatlon.  For tur1her inlormalion contaci the of 
please mall  :  Government of  2703, or fax  ii  kl Yukon  Box 
of 
Manager  Hydrology, Water ResollC&S at (867)  -3223, toll free 
667 within Yukon 
Whitehorse,  Canada  A 2C6 Yukon,  Y1 
1-800-861-0408 Exl 3223. 
Please leel free  contact 
to  us at 
IIMWrNdlheabowc:JauHMtd 
,_,,..,.._lb,, 
Phone Toll  free  (in  681-0408 3171) 
: (867) 8&7•3171,  Yukon): (1-800)  , local 
Fax:  : Watar. .yk.ca (867) 667-3195 E-maH RelourcesOgov
collKtionolpenona/Jnfbtmatlon.  SignatureofWellOwner