sheet  __ __ of 
WEllFORM 
Impact Drllllnu  861-668-&943 
6"  •  •  •  •  •  • 12"  Water Wells  Pump  Installation  Exploration  Dual  Rotary Air  Rig  Pilings 
Owner  name:  s;'  '"j \  v, , , ·b 
Malllng address:  ____________ City/ Town:  14! b ,:kl av~ o 
Prov./Terr.~ Postal  Code  ____ 
_ 
st-
O 
Well  Location  Address:  Street  Street No.  L  I  ii  name  Cc, '"  v"S  y<  ol 
L 
City/Town  Le (J.,t  e,  ,e 
G /{ 
Legal  description:  Lot  Plan  ____ D.L.  ____ Block 
PID:  Description  of  well  location  (attach  sketch  nee ):  __ J 0-'--.JC ' ~  _ _ _ _  _ ...Ll. '--'-C\=Uo..:,:-' ,,_e±:r....___,:h~<.J_,u'--'S,._,.S;, 
.
A  ,  v 11r )(  C:: <.) ' 
1 7' 
Q 
NAD  83:  Zone:  _______ 'ANij'I  UTM Eastlng:  O'.'l}5:/ / ':{ < l  fi  r,;;;'1  Latitude: 
. m 
l!!!!!!I  UTM  Northing:  6 6ft  I 1c,  53  0 rJ  111  l!!!!J  Longitud 
VTM  "2.-DN-f--
D  D  D  D  D  D  D 
Method  of  drilling:  air  rotary  D dual  rotary  rotary cable  tool  mud  auger  driving  jetting  oi 
S-111/-0o 
c 
_ 
Orientatlonofwell:li)-vertical  Ground  elevation  1 '-< 'i ""  ft(asl)  Method:
_ _ 
Class  well:  ______________________
of 
/,,(f'llt,9,0r-J 
j 
Water supply wells,  indicate  water  use:  liJ.(rfvate  domestic  water  supply  system  irrigation  commercia
D  D  D 
~-
other  (speclty) 
D 
-
LITHOLOGIC  DESCRIPTION 
Surficial  Material 
Bedrock  Material  Water  Content 
Hardness  Observations 
Color 
(e.g.  other  geological 
, 
materials  boulders)
(e.g. 
est.  water  bearing  flow 
. 
(USgpm) or closure 
From  i  To 
details) 
ft (bgl)  (bgl) j  ft 
,'\  i  -, 
o:o:o,oioioio oioioioioioioio oioioi loioioio oioioio oioioioioio  -<tt
oioioioioioi~ o[oioioio:oioio oioi• ioioio!oio oioioi~ oioioioioio 
J 
oioioioio!oi•  oioioioioioio!o oioioioioioioio o!ofoio oioioiofoio 
d ,~ 
oioioiofoioio ofoio[ofoioioio oioioiofoioioio oioioio oioioioioio 
v(  I<'  r1 J.1 
oio 1 oioio!oio oioioioioioioio oioio!oio!oioio oioioio o;oioioioio 
o!o!oioioioio oioioioioioioio o:o,oioioio!oio oioioio oioioio!oio 
oioio!o!oioio oioioioioioio!o oio,oioioioioio oioioio oioioioioio 
oioioioioioio oioio!oioioioio oioioioioioioio oioioio oioioioioio 
1
o:o,oioio!oio oioioioio oioio oioioioioioioio oioioio oioioioioio 
CASING  DETAILS 
SCREEN  DETAILS  f:.  , .  ;.; 
I  . 
1
Surface  seal:  Type  __ ..J. '- = ,..,, .. ~'t· r,c ··  · :i,,,._·,.hA __ Depth  _j_£_ ft  Intake:  Screen  Open  bottom  Uncased  hole 
.  v~ D  D  D 
: 
Method  of  installation  Poured  Pumped  Thickness =,,J...E__ in  Screen  type Telescope  Pipe  size 
D  D  D  D 
D  D  D 
_ 
ft 
Backfill:  CJ  7 - /  "".I  J.J:1_. ..  material:  Stainless  steel  Plastic  Other:  _____ 
Type  Depth Screen 
I  8 
Screen 
Liner:  Q.J'VC  Other (specify):------------ opening:  Continuous  slot  Slotted  Perforated pipe 
D  D  D 
D  D  D  D 
_ 
in  in 
Screen 
Diameter _______  Thickness  1 ',U  bottom:  Bail  Plug  Plate  Other:  _____ 
J .(',.,...  I ft 
From.....0:1-ft bgl)To~ft(bgl)  (:, "( 
in 
Filter pack:  From  ___  To:  ___  Thickness:  _____ 
ft 
I 
To 
Perforated:  From  .1.Sffi_  (bgl)  4- (bgl)  +- <f. 
ft  o 
ft 
9 
Type  and  of  material: 
size 
DEVELOPED  BY  FINAL  WELL  COMPLETION  DATA ••:  >:;  :/  .· 
' , 
lla"llir  •  .  ~ / 
lifting  Surging  Jetting  ~umping  Bailing  Total  depth  drilled:  /Cf . 7  Fi ell  depth:  fl "f 
ft 
D  D  D 
ft(bgl) 
1 
2 
(specify) -------- Total  duraUon:  ..  .,!;i\l~qk.up 1',,' ., t '&:' ,,,_.,,,in Depth  to  bedrock  q 
Other 
: - .- -_  -, - ~  , '  ,,  ,., : 
(bgl) 
ft 
·.  . "'' 
5 2 
.c'
(bgl) 
Notes ..  -<t.:....  :!;S! !',;, ,,.. ->- A•...,>ll,,,  SWL:  Estimated  well  yield  2 ,,; 
:  ' 
ft 
USgpm 
WELL  YIELD  ESTIMATED  BY'  . 
II]1>umping  Bailing  D Other  (specify):______  Artesian  flow:----- USgpm,  or Arte~ia.l}.~ressure:  ___ 
ft 
:  : 
of 
Rate ________ USgpm  Durtation: _____ hrs  Type  cap L K- l{  D 
'f Well  dislnfect~d:  P,Yes  No 
well 
~ 
ft  ft 
water 
well 
SWL  before  test (btoc)  Pumping  level:  (btoc)  Where  ID  plate  Is  attached: 
: 
J' 
WELL 
OBVIOUS  WATER  QUALITY  CHARACTERISTICS  CLOSURE  INFORMATION ;·  -' 
I 
. '  ' 
Clear 
D  D  D  D  D  D 
Fresh  Salty  Cloudy  Sediment  Gas  Reason  for  closure: 
1  \ 
1 \ 
of closure: 
Colour/  Odour:  Water  sample  collected Method  Poured  Pumpe~ '-J 
D  D  D 
:  -
• 
WELL  DRILLER  (prJ nt cleartyl  '.  Sealant  Material:  _____ Backfill  material:------
11 
_ 
of closure: 
.,._, 11[[  ,  Tl:  / 
Details  _______________ 
V  , 
Name  (first,  last): 
Consultant  (if  applicable;  name  & company)  _______ TL_ __ 
DATE  OF  WORK,/wvv/rnm/dd)  '.l 
. 
- q' _ 
Completed  4--1 d  _ .. .....,_  _._ '7 ""'-' C\ )_-1-
Started: 
.  \  \  ' •• • 
of 
Signature 
Y1 
l  ' 
Comments:  (J 
Driller  Responsible 
d ,  , 
or  closure 
works 
PLEASE  NOTE: The  information  recorded  in  this  well  report  ll-r1bes  the  the  the and  hydrogeologic  conditions  at  time  of  co_nstruclion alte~tion  as  case  may  be. Woll  yield
well  and  and as  may 
performance  quality are  are not  quaranleed  th Influenced  by  number  factors,  Including  natural  varlab11ity,  human  actlv1tlas  condltmn  the works,  Which 
a 
water 
~ 
of  of 
change  over  time. 
WHITE:  CUSTOMER _ I  :  I COPY  COPY  COPY YEUOW YTG  PINK:  DRILLER 
\ ' ,  I ,I