w5, sheet __ of __ Impact Drilling 861-668-6943 WELL FORM 6" - • 12" Water Wells• Pump Installation• Exploration• Dual Rotary Air Rig• Pilings Ownername: Uc:· , C l. , (,,\, c._ ,. .,._ (,.- ...j.. / v':x,,h,1 ,._ ( C, /.,, ,, .. _. :, c-.\ ·,, e) Mailing address: ____________ City/Town: W!~ ' _.,. L. o·· ,,;: Prov./Terr. ~ PostalCode~~~-- Well Location Address: Street No. f bC/ Street name Wru· W L: u.v l (, City /Town I '?Ju n,, t'\- i: ~ ~(, @IDLegaldescription:Lot D.l. ____ Plan ____ ____ Block d / -( J 1 0 1 1 ' ' I @ID PIO:-----~-@ DescriP,lilJ!l of well location (attach sketch ff nee.): ~' -v{. "' · •· I l-1 c, u ' ~ "'" ,, 12 A h () 11,.,,,,. '- <' .;.- ,. I NAO 83: Zone:_______ UTM Easting: 0 '-1,'i 4'7' 1 C,-6 ff m"::.@fil Latitude: 'Ami' ,., ,. o 0 1 ' J OR ·- U • N UTM Northing 6 7 J l' Longitude:_ tJ\ -Z-V I;: : > m of Method drilling: D D D D D D Dair rotary rotary ~ual cable tool mud rotary auger driving jetting other 401 :1. ', ,(o II e ~ " Orientation of well:.etvertical D ft - horizontal Ground elevation 1P '-I (asl) Method: le .,_, ".rt;{,i\;t'.~~ ~;,-7.,;r\~ ~· .,.;:,_l,~t~~: ·:,rfr\h;( 1 i · · _ Started: L/ /?, Completed c > ( .. "'\ l 0 \ I Signature of ;._l _l\ Comments: Drfller Responsible of ib PLEASE NOTE: The Information recorded not In this well report descr es the works and hydrogcologic conditions at th lime construction, alteration as the the case may be. Well yield or closure o and and as may well performance water qualtty are quarante they al influenced by number of ctors, including natural variability, human activities condition works, which ed e a fa ' of . change over ttme WHITE USTOMER COPY YELLOW YTG COPY COPY PINK: DRILLER : C _ I : I .............. ....:. ....... ...._._ -.!..<--