sheet __ of __ WEllFORM Impact Drllllng 1&1-111-&043 6" - • 12" Water Wells• Pump Installation• Exploration• Dual Rotary Air Rig• Pilings Owner name: 0"' 1,.,... ,.!- M " I t... fJ.,_~ -<.--1. Malling address: .., J City/Town: (i)bd:d,-:r.. Prov./Terr.__.Y'.l_ _ Postal Code ____ WellLocatlonAddress: StreetNo. :fl b & Iv: Streetname ':tv,c f'I City/Town ,;t\c.v., 4 (/ ~Legal description: Lot ____ Plan ____ D.L. ____ Block____ J PID: -------@ Description of well location (attach sketch ij nee.): A H r f cax '!. 0 ' i: o '- +- ,,-{' i.._ ,, F NAO 83: Zone: _______ UTM Easting: d' •L I Mo Z.(: 'oii' Latitud m Tri,/\ 'UJN t g U Z UTMNorthlng: (7 17 0S? Longill m Method of drilling: Erdual air rotary rotary cable tool mud rotary auger driving jetting 1 D D D D D D D l:>034-35' E. Orientation of well: Dvertical ) horizontal Ground elevation 9 ft (asl) Method:_ D 7 Classofwell: ___ _ ______ ___________ ___ ---l (,, I 1-0 ti rJ Water supply supply wells, indicate water water use: ~rivate domestic system irrigation D commercia D D D other (specify) - - LITHOLOGIC DESCRIPTION · Surficial Material Bedrock Material Color Hardness Water Content Observations (e.g. other geological (e.g. materials boulders), est. water bearing flow (USgpm), or closure From To details) ft (bgl) ft(bgl) f, : /C- ~:o:o:o:o:o:~ 0:0:01 01 0!0!0!0 o:o:oio!o:0:01 0 o:olo:~ a:o:o,o:olo o:o:o!o!o!o o!oiolo!oiofo:o olo!olof@ lo\oio 0:0:0: 0:o:o,o:o i~ 01 ~! o!oio!o!o:o!o oio!o!o!o!o!o!o olo!oi~!o!o!o!o o:~:o:o o,o:o:o:o!o ~o 1n t 1 I ~ ~ -,.-1, ,J'I : Notes SWL: '1 0 Estimated well yield ____ USgpm ft (bgl) BY WELL YIS.D ESTIMATED ~=..:.==-====-=----------------,Artesian flow: ____ _ USgpm, or Artesian pressure: ___ ft Pumping DAir lifting Bailing Other (specijy): ______ L D D D D Well disinfected: [!-'(es No well Rate: _________ USgpm Durtation: ---,---hrs cap: cd '"':) of Type water : SWL before test: (bloc) Pumping level: (bloc) Where well ID plate attachedis ft ft OBVIOUS WATER QUALITY CHARACTERISTICS WELL CLOSURE INFORMATION - · : Fresh Salty D.Gfear Cloudy Sediment Gas Reason for closure: D D D D : : Colour/ Odour Water sample collected Method Poured Pumped D D D of closure: _ Sealant Material: _____ Backfill _____ material: ly 1-!WEU-=~D~R:::IUER=c!!(P::,:rl:;:nl..::Cl:::ea:.:,r',f-)----;.--;;'T:""--,;---~"i ,. · of closure: Name (first, _ last): ~ _--J{l...~>:..1.., F""I ~-"'-' µ._--""-"'A'.-1,.i,.... '-....._,,lf)'ll ti"----- Details _______________ & _,_ _ Consultant (H applicable; name company) ____ ___ 1-:DA=:rE=OF=W=O=R=I(= l(vwv =,im=_ m/=d=d=::;::;::::=:::;:==:::==::::==::::.j 1 ) _ , I 1 Started: A u 'l, Complete~ Av- ~ 'j { 9 of Signature I , , · 1-1.0 • ' Comments: }I. .• IL t:,. ·• · - ·· •• Driller Responsible _ _ PLEASE NOTE: Tile 1nrorrnatioo recorded 1n this well report desert-!!½ the the the works and hydrogeologlc coodltions at time construclioo, alteraUoo or closure as case may be. Well yield, of of and may well performance and water quality are not quaranteed as they are influenced by number (actors, Including natural vanab1hty, human act1vlt1es condition or the works, Which a change over time. ' WHITE: CUSTOMER COPY COPY COPY I I YEUOW: YTG PINX: DRILLER