sheet  __ of  __ 
WEllFORM 
Impact Drllllnu  1&1-111-110 
6'; -12"- P m!_Vyate i:_','.l'Jl~.!-- JJ p-\nSia\\ a'tion  •Exploration•  Dual  Rotary  Air  Rig•  Pilings 
Ownername:  r  1- .  ·,  r'I... .. L I  1, _  l\ 
Malling  address:  _____ ___....,1.\_  City  /Town~  .  .~  - ~ -(ti L"  Prov /Terr Postal  Code --
_ _ _ _ 
:  < ) 
. 
Well  location  Address Street  Street No ':::I ~,  name  t"'.(  "'J -,  1:1  C.l\;d  "  City/ Town  C-"'t  ,. ;,  bi/,,  / C, i 
@ID  legal  description:  lot  Plan  ____ D.l.  ____ Block 
@ID 
PID:  Description  of well  location  (attach  sketch  tt  nee.):  _J W i2  ' ,,.J.  ,,,  <J  /cw,  11.P_ 
,_  "  - 1  / ~,  lfr'e ----
Ol\l(;J  C.O~RT>l~ SI 
~l <f'l NAD83:Zone:  _______ @fil  UTMEasllng:  oi "f '.3  Cm  Be1. '.:)V~ f, ~ ;  .  -----
I  @I  t 
UTM  Northing:  G  M  . 7  '.1  i  '1  '1  m  t..rrt\/1 
I 
r  D  D  D  D  D  [ 
2 
Method  of  drilling:  Dai rotary  rotary  rotary dual  cable  tool  mud  auger  dnvmg  '2-1l t,J  e 
D  D  ft 
of 
Orientation  well:  vertical  horizontal  Ground  elevation  _______  (asl)  I). U  l tJ  "I 
_ _ _ _ _ _ _ _ _ _
Classofwell:  __ __ ___ ___ -----j 
7 
Water  supply  supply wells,  indicate  water use private  domestic  water  system  irrigation  L  It  3  '1 
0 S 
: D  D  D 
D 
other  (specify) 
LITHOLOGIC  DESCRIPTION 
Suriicial  Material  Material 
Bedrock  Color  Hardness  Water  Content 
Observations 
(e other  geological 
.g. 
materials  boulders), 
(e.g. 
I  i 
. 
est water  bearing  flow 
i  (USgpm) or  closure 
, 
From  To 
) 
details
ft 
ft  (bgl)  (bgl) 
l 
a l, , !lll!li I  I i  li I I  ijl :i  ,  I  I  I , i~ l  ii  j J ,  I ! 
oiolo!o oio ololoioio!ololo olol 0:olo!olo oloiolo  oiololo o l~ 1EJl lill
oloiolotoio ololoto!ololo!o o!o!o!olo!ololo olo:olo ~lololo!o o 
i~ 
ololololololo o!ololololololo ololololo:ololo olololo olololoio o 
: 
r 1--s  11 f. 
~loloioioloio olololololololo olololololololo ololoio ololololo o 
l
i1 
L:  'j  L. 
oiololololo oloiololoioloio olololoiolololo o!ololo olol l lo o i<iil  ,. <J
oloiololo!olo o!ololololoiolo o!olo:o!ofololo 01 01 01 0 olololoio o 
olo!oioioloio oloioioiololo!o ololololoiolo!o ololo!o ololofo!o o 
ololololololo oloiolololoiolo olololoio!ololo 01 01 01 0 o!oio:olo o 
ololololololo olololo!ololoio o!o!o!o!olololo oiololo olololoio o 
oloio!oiololo oiololo!o!olo!o oiolo!oioio!olo oiolo!o olo!oloio o 
CASING  DETAILS 
SCREEN  DETAILS 
To 
From  I  I  Dia  Wall  Drive,;  From  !1  To  Dia 
. ' 
Slot 
f  Type 
)  /  ! 9!s  ,  ft 
I  I  I 
f!  i  In  Casing  Material  Open  Hole  h1c~n ! Shoi; t  !  in 
ft  (bgl)  (bgl)  (bgl)  (bgl) 
Size 
11 
J 
i 
0  • 
: 
Surface  seal I "-
Type 
ft 
Depth _lS__
D  D  D 
Open 
Intake:  Screen  bottom  Uncased  hole 
Method  of installation  Poured  Pumped 
D  D 
Thickness --Lil.. 
in 
type:  Telescope  Pipe  ze 
Screen 
D  D  si
: _ 
Backfill Type  __________ 
ft 
Depth  ___ 
Screen  material:¢tainless  D  D  _ 
steel  Plastic  Other:  _____ 
_ 
PVC  Other  (specify):  ___________ 
opening: ~ntinuous slot  Slotted  Perforated  pipe 
Screen 
D  D 
in 
Screen  bottom
Diameter  _______ in  Thickness------ Bail  IZI-Pliig  Plate  Other:  _____ 
: D  D  D  _ 
To 
___  ___  Filter  pack From  ___  ___ To:  ft  Thickness:  _____ 
in 
From 
ft  : 
ft  ft (bgl)  (bgl) 
From 
Perforated (bgl)  Type  and  size  of  material
To 
:  : 
ft  ft (bgl) 
DEVELOPED  BY  '  FINAL WELL' COMPLETION  DATA 
D  D  D  D  ft  :-~/~,.___,'-~-til.AiMiftlng  Surging  Jetting  Pumping  Bailing  Total  depth  drilled:  I 5' «>  Finished  well  depth
ft  (bgl) 
:  t'ictl :  ;  :  ft 
(bgl) 
in 
Other (specify):-------- Total  duration ---hrs  Fina1's up 9 ''  Depth  to  bedrock 
L!!!No~te~s==================:.l  I  / O 
: ' 
: 
WELL  YIELD  ESTIMATED  BY  SWL O  Estimated  well  yield  ---'-~-USgpm 
ft  (bgl) 
(specify)
D  D  D  : : ft 
Pumping'-0 Air  lifting  Bailing  Other  ------ Artesian  Artesian flow ----- USgpm,  or  pressure:  ___ 
hrs 
Rate ________ USgpm  Durtatlon _____  well  cap:  L  c.),( '"1  Well  disinfected (w-(e's  No 
Type  of 
a
:  :  :  D 
water 
Pumping 
SWL  before  test (bloc)  (bloc) 
level
ft 
:  : 
Where  ID  plate  is  attached: 
well 
ft 
OBVIOUS  WATER  QUALITY  CHARACTERISTIC$ 
WELC  CLOSURE  INFORMATION .",'. 
' 
Fresh  Salty  Cloudy  Sediment  Gas  Reason  for closure ______________ 
D  D  .cklear  D  D  D  :  _ 
Water 
: D  : D  D  ed 
Colour/  Odour:  sample  collected Method  closure Poured  Pump
of 
Material
a )\  •  •  - ,  :  _ 
WELL  DRIUER  (p rint de rly Sealant  _____ Backfill  material: _____ 
, k  \ 
of 
closure
':, ,("  ..,.___  II  \/I  Ir  -•  c1/v'  Details  _______________ 
\ 
:  _ 
Name  (flrat, last): 
_ 
Consultant  (if applicable;  name  & company)  ________ 
of 
Signature 
Driller Responsible 
:  i In  a 
PLEASE  NOTE The  nformatioo  recorded  this  well report  describes Ih works  and  hydrogaologlc  condlllons  at  the  the time  of  constructioo,  alleratloo  as  case  may  be. Well  yield 
or  closure 
wen  performance  and  water  quality  are  not  quaranteed  they  are  ln fivenced  by  number  ctors,  Including  natural  rlablllty,  human  activities  condition  of th works,  which 
as  of  and  may 
a  fa va e  ' 
change  over time. 
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