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Impact ornnnu  861-668-&943  \ / · 1 ~"  sheet- o1  _ 
WEllFORM 
6"  - •  •  •  •  • 12"  Water Wells  Pump  Installation  Exploration  Dual  Rotary  Air  Rig  Pilings 
,~ 
{V\  AA~ 
(J.  111\ G< 
s 
Owner name: 
cl ) b,.  1½-tr µpg...Prov.  /Terr.~ Postal  Code 
City  /Town: 
Mailing  address: 
I c.. 
(± n±±I:< v. .d f., J..  City/Town  WdlE cJ, 
Street  name 
Well  location  Address:  Street  No. 
Plan  Block 
D.L 
;  lot legal  description: 
<; /:_ ~ 
-l 
t[ 
bo ..  <-
b 1 ~ !:: :f:
Description  of  well  locatlon  (attach  sketch  tt  nee.): 
PID: 
--
f!  1-,o ' 
UTM  Easting:  I (.. !~  '.?i. F' 
m 
NAD  83:  Zone:  --
latlt~ 
Q, 
@) 
N t 
W 
UTN1 
UTM 
Northing:  {; ] t  ~i  0 1.  I\J 
m 
long 
Method  of  drilling:  19-:lir rotary  rotary  rotary <C11ual  cable  tool  mud  auger  driving  jetting 
D  D  D  D  D  [ 
t;o I 4 II=> 
ft (asl) 
D  Method:_ 
horizontal 
Ground  elevation 
Drientatlon of 
well:  £a-vertical 
of 
Class 
well: 
Lt  -:=t  lq 1)-?» 
Dcommerci 
water  system  irrigation 
Water  supply  supply 
wells,  indicate  water  use:  D,irivate  D 
domestic 
other  (specify) 
D 
,---
LITHOLOGIC  DESCRIPTION 
Observations 
Content 
Water 
Hardness 
Surficlal  Material  Material Bedrock  Color 
. 
(e.g other  geological 
i 
; 
i 
materials (e.g.  boulders), 
i 
ii 
... 
; a:::i 
est water  bearing  flow 
! 
! 
l  !
i 
(USgpm),  or  closure 
j 
i:l 
g(  g 
! 
details) 
¥ 
lit 
From  To 
il 
i! 
i 
ii 
g!) 
I  j 
j 
f_§ 
) 
ft  ft 
(bgl)  (bgl)  § 
i 
!  iJ 
~li 
!Iii! I  I I  !\  !,  i 
i!!  Iii :l!  iii 
,..,, 
o> 
j  0:01 0:o!olo:a olo1 01 oiojoio1 0 otolo1 o[oiololo oloiol ~:0:0:01 01 0 
'l, 1. 
["10 
.11 :0:oto:o:o 
'1'2. 
• :ololo:oioio olololo:o:o!oio oio!o:oio!oloro oto!o!o 
"! () 
lf) 
oio\o:o:oioj oio!o\oio!oiolo otoioio!o1 o!oio 0!OiO!0 olo:o:• iolo 
Gf/ 
! I~  oloio:01 ololo ololo:o:o!o!o\o olo:o:0!0!01 0!0 OiO!0iO 01 0:0:ololo 
q , 
-I  -e e.  ( '  l...;,J ,. 
!"
(< 
/'i 
01 01 01 0!0\olo ololo!olo!o:oio o:oiolo!oio!oio 01 01 0!0 oiolo!o:o:o 
0!0!0!0!01 0!0 o\o\oioio\o!olo o:oio\olo!o\olo o!oioio 01 0:0:oioio 
; 
olololo:o:o!o 01 oiolo:o!o[ojo ojoio!OiOiO!OjO olo!o!o oioiolo:olo 
i 
oloio:oiololo oioiolo!o!o!oio oio!oio!o,oiolo olo!oio olololo:oio 
ololoioiolo!o ololololo!o!olo oloio,o!oioiolo o!oiolo o:o:o:o:o:o 
o:o!olo!olo:o o!olo!ofoio:o:o o!o:o:o:o:ofo:o ofo\o:o oio:o!o:o!o 
CASING  DETAILS 
SCREEN  DETAILS 
i  ; 
Wall 
! 
Slot 
From  l  l To 
To 
Dia  From  f  Dia 
j 
Driv
) 
Type 
[  / 
Casing  Open  Hole 
Material 
! 
Jhickne~s 
Size 
) 
ft  ft  ft 
!  in 
(bgl)  (bgl) 
! 
It (bgl)  {bgl)  I~  in 
Sho
t _  ·; 
•  , 
,n 
i 
'-.. _.I(_. 
Q 
() 
(" ~ 
'2-(9.  lt ?- ?ri 
q
:9 '-\  <·n 
!
hX 
JJ  17 
..., 
' 
i 
~,.,.JL,,. 
Depth  ---15:._ 
ft 
Type 
Surface  seal: 
Intake:  13'1,creen  bottom 
D  D 
Open 
Uncased  hole 
Method  of  installation  Poured  D Pumped  Thickness  _J_Q_ 
in 
D 
Screen  type:  l2'relescope  Pipe  size 
D 
___ 
Depth 
ft 
Type 
Backfill: 
Screen  material:liJ'Stainless  steel 
Plastic  Other: 
D  D 
D 
PVC  Other {specify): 
opening :~ontinuous  slot  Slotted  Perforated pipe 
Screen 
D  D 
in 
in  Thickness 
Diameter 
Screen  Other: 
bottom:  Bail  efiug  Plate 
D  D  D 
ft  ft 
From  To 
(bgl)  (bgl) 
___  ___ 
ft 
___ 
To: 
ft 
___ 
Filter  pack:  From 
: 
Thickness
in 
ft  ft 
(bgl)  (bgl) 
To 
From 
Perforated
: 
Type  and  size  of  material: 
:·, 
FINAL  WEU  COMPLETION  DATA 
DEVELOPED  BY 
f, 
Pumping 
D  D 
Q.Air lifting  Jetting  Balling 
9 
Total  depth  drilled: 
· 
ft 
Finished  well  depth: 
lt(bgl) 
91 
,~ ,, 
: 
Total 
___ hrs 
duration
Other  (specify): 
·
Final  stictiup: 
in 
Depth  to  bedrock 
: 
(bgl) 
ft 
Notes: 
'-
~ I 
SWL: 
ft 
(bgl) 
Estimated  well  yield 
USgpm 
/ 0 
WELL  YIELD  ESTIMATED  BY 
Artesian  flow: 
ft 
USgpm,  or Artesian  pressure:  ___ 
D 
Other  (spectty): 
Bailing 
Pumping  L,l"Air  lilting 
D 
:.CYes D 
Well  disinfected No 
c~ 
Type 
of 
well 
hrs 
USgpm  Durtation: 
Rate: 
level:  Where  ID  plate  Is 
well 
Pumping 
water 
attache 
ft  ft 
SWL  before  test (bloc)  (bloc) 
:  . 
WELL  CLOSURE  INFORMATIDN 
DBVIOUS  WATER  QUAUTY  CHARACTERISTICS 
Reason  for closure: 
Fresh  lid'Clear 
D 
Salty  Cloudy  Sediment 
D 
closure: 
Method 
of  Poured  Pumped 
D 
Colour/  Odour: 
: D 
Water  sample  collected
:  : 
Sealant 
Material
Backfill  material
(\ 
WELL DRILLER  (prtnt cle!lfly) 
A  A 
of 
closure: 
Details 
I \l
"'"  VV L I<  clOJr. a- l-i 
Name  (first,  last): 
I 
Consultant  (if  applicable;  company) 
& 
name 
-'~ 
DATE  OF  WORK  (yyyy/nim/dd) 
(
Vw,.  2ti q. 
(
1. J( '\ 
(\i\'4. 
Completed 
Started
: 
of 
Signature 
cf" 
u 
~l OJ 
K 
Driller Responsible 
Comments: 
PLEASE  NOTE: Toe  Information  recorded  in  this  well  re r,~escrlbes  Ille  Ille works  and  hydrogeologlc  conditions  at  the  time  of  construction, alteration  as  case  may  be. Well  yield 
or  closure 
well  and  and  of the 
performance  water  quality are  are not  quaranteed they  influenced  number  of  factors,  Including  natural  variability,  human  activities  condition  works,  which  ma 
. s  b a  ' 
change  over  time. 
WHITE CUSTOMER  COPY  COPY YELlOW:  YTG  COPY  PINK:  DRILLER 
,  I  I