\/  I ( L  l  sheet  __ of  __ 
Impact Drllllnu  1&1-&&1-&943 
WEUFORM 
6"  - •  •  •  •  • 12"  Water Wells  Pump  Installation  Exploration  Dual  Rotary Air  Rig  Pilings 
Ownername: __ 4-H:1_;Llo R ~l--" ~ b~P~r..1+:._..1 '"L.,__ _____ ----,r.,,----..-,.-,"'-----;-r-;:--------
Malllng  address:  ______ ---,- "-,----- City/Town:  f:'l~~r
"'- 1-lw :;1  VJ  Prov./Terr. ~  _ Postal  Code  ____ 
0
I 
Well  Location  Address:  Street  Street No  Lo±  I  l • '>I  :Z  name  UJ • J  "'J  6J.  City  Town----------
_ 
Legal  description:  Lot ___  ___ Plan  D.L,  ___  __ Block 
PID:  Description  of  welllrr.:oflnn  ,.11.r.h skatr.h  nor.\· ii  /_.(',ti  uf  F=' I!  ci 
A  PP61 Y  I 6 0 I  -------------
_ 
itude: __________ 
! 
NAD  83:  Zone:  _______  UTM  Easting
1gitude:  __________ 
_ 
UTM  Northln T)J\  "2Al II/  g 
l 
V 
e 
Dother(specify)  _______ 
_ 
Method  of drilling:  8'!!rr  D  D 
rotary  ll!l'tlual  rotary  cable  tool 
· D 
of 
Orientation  wen: li!t1ierncal  horizontal  Ground  elevation 
cJ-'rlJ 2-:, 'l  e 
Classofwell:  ____________ 4 
N 
u"IL}ul~,; 
1rcial  or  industrial 
Water  supply  wells,  indicate  water  use: lli:l'iirivate  domestic 
D w 
other  (specify) 
D 
LITHOLOGIC  DESCRIPTION 
Observations 
Water  Content 
Hardness 
Surlicial  Material  Material Bedrock  Color 
(e.g.  other  geological 
materials  (e.g.  boulders), 
est.  water  bearing  flow 
(USgpm),  or  closure 
details) 
From  To 
ft(bgl)  ft(bgl) 
~!o!o\oroio!o olo[o[olo[olo[o olo:oiolo[o:o o o!@ [o,o 
9  o'e[o:o[o,o 
l'l 
~ [ foio,o[o[o 01 0[0[0!0[01 01 0 0[0[01 0!0:olo o o[• :o!o or• fo[o[oro 
i.., ,;  ei ne~,.,.-L~u< t-
q  [ 
~J A.,,J  ,  , 1, L~ 
o[o,o:o,o[o!o o[o:0!0!0!01 01 0 olo!o[oioiolo o o:@ rolo 01 0;0[01 01 0 
1
:  0 0[0[0[0!01 0 o!olo[o!o[orolo otoloto:o:o,o o oi@ lo[o o[o!o[oiolo 
1 r 
6c  1. f.,  r<. 
1
, "i:c  ,;,,  w<ftcr 
i ' · oio!olo[olo 0 oiofolo[o[o:o:o o[o[olo!olo:o o o[ofolo 0:01 0!01 0[0 
, 1
'l')(\ !  o!o!o!o[oio[o 01 olo!olo!ololo o,o[o!o!o!olo o oiofofo 01 oio!olo1 0 
'11  v  ,, ,, ., .,. 
1
~, 
2  1 0!01 0 0:01 01 0 olo!oio!o[olo:o o:olo[o[o!o!o o o:o:~,o 01 0[0[0!01 0 W 
0[01 0[0!01 0:0 o[o!o:o!olo:o!o o!o!ololo,o:o o 01 0[0!0 01 0[0!0:olo 
).<; <;-:  -in 
CASING  DETAILS  SCREEN  DETAILS 
Slot 
Type 
ti(g~)  11  (igl)  f
I  I  ! Casing  Material/ Open  Hole  hi!~~ 
j 
Size 
i 
;  •  j  In  ; 
Surface  seal:  v'.\  Depth  ---Is::.-- ft  Intake:  Screen  Open  bottom  Uncased  hole 
Type 
A "  D  D 
O 
Method  of  installation  Bl.foured  D  Thickness-'  D  D 
Pumped  O __ in  type:  Telescope  Pipe  size 
Screen 
Backfill:  ___________  ___  Stainless steel  Plastic  Other: _____ 
Depth  ft  Screen 
Type 
D  D  _ 
D  D 
Liner: p,PVC  Other  (specify):----------- opening:  Continuous  slot  Slotted  Perforated  pipe 
Screen 
0  O 
Screen 
in  in 
Other: _____ 
Diameter  '-I · r 
Thickness -~'2~~-~Q~- bottom:  Bail  Plug  Plate 
D  D  D  D  _ 
From  To 
--1.2.. ft  ft  ft (bgl)  (bgl) ..J:..:z2  Filter pack:  From  To:  ___  Thickness:  ____ in 
___ 
ft 
To 
size 
ft 
Perforated:  From  --1.2.:2....  (bgl)  ...:1.12  (bgl)  Type  and  of  material: 
ft 
, 
DEVELOPED  BY  FINAL  WELL  COMPLETION  DATA f  ;,  ./  -' 
7 
ft  ft 
(bgl) 
~r lifting  Surging  Jetting  Pumping  Bailing  Total  depth  drilled:  _]_Ji_  Finished  well  depth:  '1 I 
O  O  O  O 
Other (specify):-------- duration:-- ~'.s  .Einal.sti~ up fi:'. ·  Depth  to  bedrock  .. 
in ft  (bgl) 
Total 
.- .-. , •  :  · /  .  :  _ .  .  . 
l,.!N!!!ot~es~============= ·  = ·  ·=====-l SWL:  2  k>  Estimated  well  yield  5  ~ , USgpm 
ft  (bgl) 
:  ·  •
WELL  YIELD  ESTIMATED  BY 
i-:=.:=-~==-===:=.;:.;._ ___________ --tArtesianflow:  _ 
____ 
USgpm,  ___ 
ft 
or Artesian pressure: 
D  D  _ 
lifting 
Pumping  la,\ir  Bailing  (specify): 
_____ 
Other 
0 
Rate:  ________ USgpm  ourtatlon:  hrs  Type  of  well  cap:  ___  Well  disinfected:  No 
_  !!:hes D 
____ 
well 
Where  ID  plate  is  attached: 
water 
ft  ft 
SWL  before  test:  (btoc)  (btoc) 
Pumping  level: 
.. 
· 
WELL  CLOSURE  INFORMATION 
OBVIOUS  WATER  OUAUTY  CHARACTERISTICS 
D  D 
O  O  O 
Fresh  Salty  JI;I.Ciear  Cloudy  Sediment  Gas  Reason  for closure:---------------
of 
Colour  Odour:  Water  sample  collected:  Method  closure:  Poured  Pumped 
/  D  D  D 
WELL 
DRllilR (print clearly)  Sealant  Material:  _____ Backfill  material:  _____ 
•  _ 
Name(flm,last):  /I•  _ 
/ '-. 1 r, fl t. IJ  Oetailsofclosure:  ______________ 
L, 
name 
& 
Consultant  (ij  applicable;  company)  ______ I  _ __ 
DATE  DF  WOR!(  (ww/mm/dd)
'  • 
Q 
4 
Completed  S:  rt 1- d  1 
Started:  <;:  lif 
+ 
of 
Signature 
Driller Responsible 
Comments: 
PLEASE  NOTE: The  information  recorded  In  this  well  report  they 
de\dbes  the  works  and  hydrogeologlc  conditions  at  tha time  of  construction,  alteration  as the  the 
case  may be. Well  yield 
or  closure 
of  of 
well  pertormance  and  and water  quality  are  not  quaranteed  es  are  Influenced by  number  factors,  Including natural  varlablllty,  human  actl~tles  condition  works,  which  may 
a  ' 
change  over 
time. 
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