sheet  __ 01  __ 
Impact Drilling  861-668-6943 
WELL  FORM 
6"  - • 12"  Water  Wells•  Pump  Installation•  Exploration•  Dual  Rotary  Air  Rig•  Pilings 
Mailing  address:-----~--~--- City /Town :  _ _______ Prov.  /Terr.  ___ Postal  Code  ____ 
. 
WellLocationAddress:  StreetNo Lot- 2.:S:::  Streetname  Lu'c-,  £,11eWo'j  City/Town  Lvt.  ," d'-or' C 
D.
@Legal description:  Lot  I  T 1(,,  Plan  L.  Block  t,..c{.  t  [  h.<1-1 "'- O ..._ 
1 
@PIO:------~ IANDi  Description  of  well  location (attach  sketch  ff  nee.):  --'-"""=--'--'-'---'c.,:+---'----=--'----
o  +\,_,_  V  \  "9'  n/_  •. u (  u.,,,'  ,. '2 ° /  , 
A ""  ... 
1 
v  c,  m 
NAO  83:  Zone:  UTM ~sting:  /"'\'cJ..  '-I c, 1.'  @  Latitude:  j 
: 
UTMNorthlng 67 'j'-fbr\) 11 m  Longitude  V TV\  1--0NC  SI 
Method  of drilling:  D  D  D  D  D  D  D air  rotary  rotary tklual  cable  tool  mud  rotary  auger  driving  jetting  oll 
_ 
of 
Orientation  well:  D  D  7 vertical  horizontal  Ground  elevation  21,  ft (asl)  Method:
> 
_
Classofwell:  _________________________ --11 
Water  supply  supply wells,  indicate  water  use: ta-private  domestic  water  irrigation  commerci
D  D  D 
system 
i 
other  (specify) 
D 
LITHOLOGIC  DESCRIPTION 
Observations 
Water 
Content 
Hardness 
Surficial  Material  Material Bedrock  Color 
r 
(e.g . o1he geological 
malaria~  (e.g.  t>oulders), 
est.  water  bearing  flow 
(USgpm) or closure 
, 
details) 
From  To 
ft  ft 
(bgl)  (bgl) 
olololoiololo ololololoioioio oioloiololololo ololol loioioloio ec©
la
.a1 olo 1 ololo 
,i> :!il
oioioio!otolo olololololoiolo oiololololololo olol olololololo!o olololololololo olololololololo ololo lo  lole loiolo 
dn
01 01 01 01 01 01 0 olololololololo olololololololo ololol !olololo!o 
1
olo!olo 1 ololo 01 01 01 01 01 01 01 0 olololololololo olololo ololo ololo 
01 01 01 0 1 01 01 0 olololololololo oiololololololo ololo!o olololololo 
ololololololo olololololololo olololololololo olololo olololololo 
ololololololo 01 01 01 01 01 01 01 0 ololoioiolololo oloiolo olo!olololo 
olololololo'o ololo'ololololo olololololololo ololoio oloiolololo 
ololololololo ololololo1 ololo oiololololololo 0!01 01 0 olololoiolo 
CASING  DETAILS 
SCREEN  DETAILS 
•  • 
Wall 
I 
To 
! 
From  Dia 
Slot 
Dri~ From  i  To  Dia 
i 
Type 
/
! Gasing  Material/ Open  Hole  j  hickness 
ft  ft (bgl)  (bgl) 
I  I  in  Size 
ft  ft 
(bgl)  (bgl) 
.  1
Sho i~
j 
t  ; ·  _ m  _ 
1  ,  , 
c,1  •.  1/&t 
0 
,
vl  I 
I 
0
1
Surface  seal:  Type  ___ I,:..,'~"'""" -· ,,.c;='.l...:T.=.____  Depth -1S:_ ft 
D  D  D  hole 
Intake:  Screen  bottom  Uncased 
Open 
D 
Method  of  installation  l!J.i>oured  Pumped  Thickness  _{JJ_ in 
Screen  type:  Telescope  Pipe  size 
D  D 
ft 
Backfill ___ 
Type  Depth 
: 
D  D  D 
Screen 
material Stainless  Plastic  Other:  __
steel 
:  _ _ _  _ 
Liner:  IZJ,PVC  Other (specify) ____________ 
:  _ 
Screen 
opening:  Continuous  slot  Slotted  Perforated  pipe 
D  D  D 
Y , C 
Diameter In  Thickness  'It> 
.  , 2 
_ 
Screen 
bottom:  Bail  Plug  Plate  Other:  _____ 
in 
D  D  D  D 
(bgl)  (bgl) 
From 
___ll}_ II  II --=LL1 
To 
___  _ : _
ft  ft 
From 
Filter pack:  To:  __  Thickness ____ in 
To 
II 
Perforated: ~:....'.3....1.2 It  !:::LLl_ 
(bgl)  (bgl) 
Type 
and  material: 
size 
of 
DEVELOPED  BY  FINAL  WEU  COMPLETION  DATA 
D 
lltrur lifting  Surging  Jetting  Pumping  Bailing 
D  D  D 
ft 
Total  depth  drilled:  _!jji_ 
'-/ /7 
- ~d
Fini~~ ,:':'ell  depth:  ft  (bgl) 
:  _ 
Other 
(specify) _______ 
: 
Total 
duration ___ hrs  Final  stick  up:  · ~ -...c···'-''c..~""- n' 
i
: 
Depth  to  bedrock 
ft (bgl) 
-z.  "' 
: 
L!N~ot~es::._:==============::::::~"'"::::]-- " / ~,  '-f9 
.J-c::, 
ft 
(b gl) 
Estimated  yield 
well 
USgpm 
BY 
WELL  YIELD  ESTIMATED 
_ 
USgpm,  or  Artesian  pre ss ure: 
ft 
__
Other (specify)
Pumping  B'Air lffing  : _ 
______  Artesian  flow:  ____ 
Bailing 
D  D  D 
:  : 
of 
well 
Rate _________ USgpm  Durtation _____ hrs  cap:-----
Type 
Well  disinfected:  Bi'es  No 
D 
ft 
.  :  a
Pumping 
SWL  before  test:  (btoc) level Where  ID  plate  is  tt ached: 
well 
ft 
(btoc) 
water 
OBVIOUS  WATER  QUAUTY  CHARACTERISTICS  WELL  CLOSURE  INFORMATION 
D  D  D 
- - -
D  D Fresh  Salty  [1;1-clear  Cloudy  Sediment  Gas  Reason  for  closure: -- ---------- --
Colour  Odour Water  sample  collected:  of  closur e:  Pou re Pumped 
Method 
D  D  D 
I  :  · d 
_ 
WEU.  (prtnt clearty)  ~  Sealant  Material:------ material:  _____ 
DRILLER 
Backfill 
I 
Name(fim,last):  J :  _ 
7-:.- VI/I  l,  fJO c.,.  Detallsofclosure ________________ 
, ,  .. 
Consultant  (if  applicable name  company)  ______ ___ 
& 
;  I  _ 
DATE  OF  WORK  (yyyy/mm/dd) 
~,.,_,d  LJ  ,  ,-I -, /  q 
Signature 
of 
Started:  --=--=t='--+--'---L-__ Completed  __ "'>=-=:"-+:{=:..:.......:. -'-I 
/--1-
tfl  ____  L (  1J 
I 
Driller  Responsible 
Comments
: 
PLEASE  NOTE: The  Information  recorded  In  this  well  report  descnb -lhe  works  and  hydrogeotoglc  conditions  al  the  time  of  construction,  altera11on  or  closure  as  the  case  ma  be. Well  ield 
t
well  perform~e  a  wor.J  Jay  ' and  and water  quality are  not  quaranteed  as they  ~ .  ' 
'Tinftuenced  by  number  of  factors,  including  natural  variability,  human  activities  condition  of  the  which 
c~ange  over  time. 
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