WELL  FORM 
Impact Drllllnu  1&1-&&1-1943 
p 
ump  Installation  Exploration  Dual  Rotary  Air  Rig  Pil gs 
6"  - •  •  •  •  f
12"  Water Wells• 
[ ..).J'. 
l=v-,., ..  ..... 
-
OWnername: 
City/ Town:  J "'- \I( \vi.,_  Lu..h. ~ av./ Terr. _hl Postal  Code 
Malling address: 
10 
City/ 
Street 
name  :Jc;. L  Ii\\""'- b&( aM'  Town  uJ b \ CL. 
Well  Location  Address:  Street  No. 
Block 
D.L. 
Plan 
; 
Legal  description:  Lot 
6Qu-..c.,, 
Description  of well  location  (attach  sketch  nee.): 
PID:  t~ 
RN 
O 
l..  CA  I\Q_  A  (1.A;,)L 
'1.-0 
I  I 
c.o  O ~l)<;. 
w J2.o  tJGi 
Gt1\/-e-N : 
M  > 7 '1 o;: '<-'5
e m 
UTM  Easting: 
NAD  83:  Zone
: 
§) 
cl o~ ~T 
e
6 ] '2.'{Ci  '-It'll  'j"
~H ' 
m 
IITM  Northing: 
i)TN\ 
Method  of drilling:  air  rotary  rotary  rotary efdual  D  D  D  D  D cable  tool  mud  auger  driving  jE 
1.01.Jt  '6. 
I  02,.2., 
fl(asl)  Me 
D 
horizontal  Ground  elevation 
Orientation  well:  IJ1'ertical 
of 
t 
lj  ?'2  'T--[ 
of 
Class 
well: 
system 
D 
· : 
Water  supply  supply 
wells,  indicate  water  water 
use IJ.f,nvate  domestic  w"t'2-q9"10 
N 
D J 
D other  (specify) 
LITHOLOGIC  DESCRIPTION 
, 
Observations 
Water 
Content 
Hardness 
Surficial  Material  Bedrock  Material  Color 
(e.g.  other  geological 
materials  boulders), 
(e.g. 
' 
!I 
l 
est.  water  bearing  flow 
Ii  ~ I 
l 
(IJSgpm),  or closure 
i , ' 
1l 
I 
! 
ji! 
g 
g 
t 1 t 
ie  details) 
;  ·o 
From  To 
r 
8 
ti!  J.j 
g/J 
j  j 
] 
fl(bgl) 
tt (bg0 
~  1 § $]  :Ii 
JJ 
i :  li  i  ··, 
Iii  ! 
J!l!l 
I I I I rli 1 1 
3 
i 
o : m 
I! 
) 1~~ I  ~(,((~ 
'io  oioioioioioi oio!oioioioioio oioioioi~ioloio oioioi• oioioioioio 
ij 
I 
-~ ,frl  co:,  'NI\.  , 
L to  i~l
i· ioio\oioioio oioioio)oioioio oioioioioioioi~ oio o oioloioioio 
'M~ 
<9
~ 
(.
Co
law 
<.:,.U 
oioioioio oio!o)o oioioioiolo 
i~!
V 
0 
IJ...
oloioioioio oloioioioioioio o:  i  ~ioioioloioio oio!oioioioioio o!o o  1  o i  o i~!  o i  o io oioioio oroioioio,o 
~i
"'° 
'10 
et 
':) '.:>  ct eJl\A-
i 
\<..1'.'.> I 'SU 
oio:oioioiol~ oioioioioio\oio oloioioioio!oio oioioio oioioioioio 
C- loq't " u p dl
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,ro 
t-\'1 
ol~
oio)O!O!O[O[~ o!o!oioioio:01 0 oio:o:oioloioio oioioio oioi io o\o)oioi ioio 
oioioioio!olo oioio!oioioioio oioioioio!oiolo oioioio oioloioioio 
oioioioioioio oioioioioioioio oioio!oioioioio oioioio o!o!oioioio 
, ,: 
',  ,''•>1 '•.·eJ.;:;  ',) 
. 
SCREEN  D~AILS ';""''  ,, "''Z  ''  ', 
' .
CASING  DETAILS 
. 
Wall  j  D. 
j 
Slot 
From  [  To 
! 
Dia 
! 
To 
From  Dia 
i 
Thickness  rive 
Type 
Material 
! 
Casing  Open Hole 
/ 
in 
fl(bgl)  fl(bgl)  Jji.ll,,,..-; 
!  i 
\ 
fl(bgl)  j  fl(bgl)  in 
in  Shoe 
j 
I 
: 
,~ 
- ,,,,-
-
-
-
')1-<)L-
l  1'1.:  YJ,tt;,  "2:> 
b/'c:;,
j 
1'1C..  /') 
j
O 
i  / 
/')  I~ -
u 
6 
.  ...., 
= 
; 
! 
! 
' 
l 
i  ...  J"' 
r·. 
Depth~fl 
Surface  seal:  Type 
D  D 
Intake: Oscreen  Open  bottom  Uncased  hole 
Thickness --1..Q_ in 
Pumped 
D  D 
Method  of installation  Poured 
Screen  type:  O'relescope  Pipe  size 
D 
Depth  __ fl 
:  : 
Type 
Backfill
D  D 
Screen 
material:t:fstainless steel  Plastic  Other
:  : 
Liner PVC  (specify): 
Other 
D  D  pipe 
Screen  opening Ocantinuous slot  Slotted  Perforated 
in 
Thickness 
in 
Diameter 
D  D  D 
bottom:  Bail  fl11ug  Plate  Other: 
Screen 
From  __ (bgl)  __ 
To 
(bg0 
To: 
__ 
Filter  pack:  __ 
fl  fl  fl  fl 
From 
Thickness: 
in 
fl(bgl) 
(bgl)To 
fl 
Perforated
~m  Type  and  size  of  material: 
: 
'1  - '"'  ~-
·<:•;Y.;,.,}A{J;'.'  ._, 
. 
f 
FINAL WELi.  COMPLETION  DATA
/ ''•.'", 
DEVELOPED JY 
Pumping 
D 
Total  depth  drilled:  '\ 
fl 
U 
D 
Surging 
~rlifting 
Finished  well  depth: 
ft(bgl) 
hrs 
Total 
duration
: 
: 
Other  (specify)
ft(bgl) 
: 
Depth  to  bedrock 
f 
Final  stick/{)  t '' 
in 
--:?  0 
Notes
: 
SWL:  C('C/  ,,  ft 
(bgl) 
yield  USgpm 
well 
Estimated 
WB.L  YIELD  ESTIMATED  BY 
USgpm,  or Artesian  pressure:  ___ 
fl 
Artesian  flow: 
(specify): 
Other 
D  D 
Bailing 
Pumping  0'AA lifting 
ta:M ,-4 
Well  disinfected Erves  No 
D 
: 
Type 
of 
well  cap: 
hrs 
USgpm  Durtation
:  : 
Rate
well 
Where  ID  plate  is  attached: 
fl (btoc) 
water 
(btoc) 
Pump ng  level
:  fl  i : 
SWL  before  test
" 
WELL  CLOSURUNFOIIMATION '•, 
' 
OBVIOUS  WATER  OUAUTY  CHARACTERISTICS 
: 
Reason  for  closure
la-clear 
Cloudy 
' 
Fresh  Salty 
D 
Poured 
of 
Method  Pumped 
closure: 
D 
sample  collected
Water 
Colour/  Odour
:  : 
' 
Backfill  material
: 
Sealant  Material: 
,I\ 
.. 
WELL  RILLER  (orint claartyl  A 
. D
closure: 
Details 
of 
r  ( '.::)  It)"\.,  VV\M.  \l'-'O~wl/ 
Name  (first, 1111): 
I 
;  & 
Consultant  (tt  applicable name  company) 
,. 
., 
\•  '\~, ':,'..:·i.,<~ 
'--;.. 
,{ 
" 
DATE  OF  WORK (vvvv/mm/dd) 
' 
J 
/l CC 
Completed 
tvt ~ 
Started:  v\˝t 6 
Signature  of 
,~ 
1'._~u 
: 
Comments
Driller Responsible 
closure 
: 
Pt.EASE  NOTE The  inlormalioo  recorded  In  this  we~~rt describes  the  wofl<s  and  hydrogeologlc  conditions  at  the  the time  of  cons1rucllon,  alteration  or  as  case  may be.  Welt  yield, 
r 
well  ormance  and  uar  are  not quarant  the  the are  influenc  of  fac!OIS  lncfudl ng  natural  variability,  human  activities and  condition  of  works  which  ma 
as 
water 
Q 
ity 
pert  ed  by  numbe 
a 
. 
change  over lime
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