~lfcfl" 
sheet  __ __ of 
WELLFORM 
Impact Drllllng  8&7-668-6943 
6"  - • 12"  Water Wells•  Pump  Installation• Exploration•  Dual  Rotary Air  Rig•  Pilings 
Ownername:  C.r .,., ,~  .!" VI-' "-.  41  V1 .tl .1@,"'_~ 
Malling  address:  _________ '-' ___ City/Town~ h '  e 
Prov.  /Terr.~ Postal  Code-----
Well  Location  Address:  Street  No.  ______ Street name  _________ City /Town  _________ 
_ 
@fil Legal  Plan description:  Lot  ____  ____ D.L ____ Block 
~PIO:-------,-- Description  of  well  location  (attach  sketch  if nee.): 
A paru-.:  l'i '  i'./  <iAiµ<>- '::J  bu ~  ,  - .  _ ·~ . J:> ·-
NAD83:Z~ne:  UTMEasting;~5".]i).5Pi,6\i.; riiiij  lati 1t  -
@ 
c 
UTM  Northing:  6 I  .. j''l.  '-( (:,  . . 'Kf  Long  VT t,/\  "UI  N \;  i 
t 
Method of  drilling:  D  D  . D  D 
Dair rotary  rotary  rotary dual  cable  tool  mud  .O a4ger  dnvmg  1ettmg  ij :J  't,  l50  I 
0 
:  D  ft  : 
? 
Orientation  of well l!:tvertical  horizontal  Ground  elevation  :"?/fCh.  (asl)  Method u " 
4 
Class  of  well:  I.I  ,.,_ 
· - -
1 
Water  supply  supply wells,  indicate  water  water use:  [].i,rivate  D  D  D  li 
domestic  system  irrigation  commer (Q  a  t,. ()  fl 1,.A  lG"' 
O 
other (specify) 
D  -
LITHOLOGIC  DESCRIPTION 
Surficial  Material 
Bedrock 
Material 
Hardness 
Color  Content 
Water 
Observations 
(e.g.  other  geological 
i  :  : 
materia~  (e.g boulders), 
. 
est water  bearing  flow 
. 
(USgpm) or  closure 
, 
From  J  To 
ii  ! 
g 
details) 
lt(bgl)  It (bgl) 
i 
J i  i i I  J 1  I 
]f,i  7-."n  o:o!oioio!ofojo oioiofo jo!o!o fo o:oioio oio,oio 'oio 
o:o!o!o!o!o!e 
fl,,R 
' ','i:J  ! 
o joio jo joio jo oioio jo,o!o!ofo o jofoioioioio!o o!oio jo o jo joio!oio 
'-i  7: 
o joio!o!oioio o joioioiofoioio oioio!o!oio!o[o o joio jo o jo jo,oio!o 
t  In!  oioio!oio'o 
o!o!oioio joio o!oioioio jo jo!o o joio:o!oioio/o oioioio 
o!o!o!o!o!o!o  o/oio!o!o!o 
oio!oio joio joio o!o!o/o!oioioio o joio!o 
'!-.
,  , ; 
'2 ss  J. --...: 
! o!o!oioio!o!oio 
o!o!o!oio!o!o o jo jo,o!o!o:o!o  o!oioio o!o!o!o!oio 
o!oioioio!o!o o jo jo/oio:o!ojo oio,o!o!o:o!o!o oio!oio o jo,o jo,o 'o 
ST 
'.l..
o!oio!o!o!o:o o jo joio!oio!oio o;o!o!o'oio!o!o o joioio o:o!o!o!o!o 
oioio joio joio!o o!o!o!o:o!o!o;o 0!01 0!0 o:o!o!o!o!o 
0!0!0 1 o!o!oio 
CASING  DETAILS  SCREEN DETAILS 
. 
i 
From 
To 
Dia 
1 
To 
t  ; ·  Wall  Driv From  ! \  ! Dia  1 
;  ~ ) 
Slot 
1 
lt(bgl)  j 
ft  (bgl) 
in 
(bgl) (bgl)
" _ 
i Casing  ~aterial  Open  Hole :'.l° jc ~s  Sh ")·,  , :n- -- ·"'  _.  -1  Type 
ft ft 
/  + ,h ~i .:  • tf  ·t ' . 
Size 
j 
'~i 
u 
G JQ 
')~  ·1, q  !PJf 
It 
Intake: 
Open 
Surface  seal:  Type  --:-c:!-t'----'-"e '¼A  ' _ :..:"'-..:c__ '_ 1-4-___ Depth  --1.S::..  Screen  bottom  Uncased  hole 
D  D  D 
D  D  D 
Method  of  installation  a-Poured  Pumped  Telescope Thickness  --1.Q__ in  type:  Pipe  size 
Screen 
:  :  D  D  D  _ 
Screen 
Backfill Depth  ---ft  material Stainless  steel  Plastic  Other:  _____ 
Type 
Liner ~VC Mtier (specify):  opening Continuous  slot  Slotted  Perforated pipe 
Screen 
: : D  D  D 
·  "2 
·  D  D 
u 
Thickness  Plug 
Diameter  '-1  'i  in  c:;- in  bottom:  Bail  Plate  Other: 
Screen 
From  To 
From 
_l2._ It  ---1SJ11  Filter  pack ___  To:  ___  Thickness--:_-_-_-_-_-_-_-_-_ -in 
ft 
(bgl)  (bgl)  ft 
: 
(bgl) 
From  ft  (bgl) 
Perforated:  _1gJ_  -2...2:.2 11 
To 
Type  and  size  of  material: 
DEVELOPED  BY 
FINAL WELL COMPLETIDN  DATA 
'
Surging 
~r lifting  Jetting  Pumping  Bailing  Total  depth  drilled: ...'.l.lL_ ft  Fh)ishad.well  depth: 
D  D  D  D 
2 
57 
lt(bgl) 
~=::,ispecify): -------.,- : ~ ~ J J ; .,,~- ~~=~ F.i r/  '. i: ·· -;-'·Depth  to  bedrock: 
, ~ li'il ' " ·' '/  ··
3  ,6  ll(bgl) 
1 
= (bgl) 
ft 
i..:W~ELL~Y.::IEL=D=ES=Tl=MA=m>:;=B=Y===== ========i SWL:  1  ' ° ·  Estimated  well  yield 
1../-S'  USgpm 
D  D  D  ,  · ft 
~r lifting  Other (specify):______  Artesian  flow:--.---- or Arteslan pressure:  ___ 
USgpm
Pumping  Bailing 
: 
Rate ________ USgpm  Durtation:  ____ hrs  Typeofwellcap:  L.«..¼ ,~ 
Well  disinfected:  [3-\les  No 
D 
ft 
SWL  before  test:  (bloc)  (bloc) Pumping  water  level ft  Where  well  ID  plate  Is  attached
:  : 
WELL 
OBVIOUS  WATER  QUALITY  CHARACTERISTICS  CLOSURflNFDRMATION ;;-, 
Clear 
D  D  D  D  D  D 
Fresh  Salty  Cloudy  Sediment  Gas 
Reasonforclosure:  _________ ~-----
:  D 
I 
Colour  Odour Water  sample  collected: 
Pumped 
: D 
Melhod of 
closure Poured 
D 
Sealant  Material:  _____  material _____ 
Backfill 
, : "' -
WELLDRllilll ( //1/1 "..;"  :  _ 
printctearlYl.  .J" 'lvt  V.}Ain ;,"
'( 
_ 
Detallsofclosure: _______________ 
Name  (first,  last):  ._,  rr~· -- • ,  "  • 
-f  If 
'  " . · 
name 
Consultant  (if applicable:  & company)  r 
DATE  Of WDRJS,lyyyy/mm/dd) 
, 
of 
Signature 
U 
Started:  \I  1..  I 't  Completed  (,<A,'  7-:~ 
I 
i 
( 
I 
Driller Responsible 
1 ~ 
:  V 
Comments --.r---~~
V - -
PLEASE NOTE The  lnfonnation  recorded  In  this well report  lfu; rtbes  the  works  and  hydrogeologlc  conditions  at  the  the time  construction, of  alteration or  as  case  may  be. Well  yield 
closure 
:  d
:!~:'::. and  and water  lntluenced quality  are  not quaranteed  as  they are  by  a  ' number  of factors,  Including  natural  variability,  human  activities  condition  of  the  works, which  may 
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