Well Record Page 1 of 2
WATER WELL
DRILLERS FORM
Government
Well ID:
Department of Environment
Water Resources Section V-310
Yukon Water Well Registry
Box 2703 Whitehorse, Yukon Y1A 2C6
To be assigned by Dept. Of Environment
INSTRUCTIONS FOR COMPLETING THE FORM
Metric
4. Please print clearly in blue or black ink.
5. Completion and submission of this form is the responsibility of
the drilling contractor.
6. Please specify metric or imperial units for all measurements.
1. Additional information is provided at the bottom of this form on page 2.
2. Question can be directed to Water Resources at 867 667-3171.
3. All well construction measurements shall be reported to 0.1 m or 0.3 ft.
WELL LOCATION AND OWNER’S INFORMATION
A1 Well Name:
First Name
Imperial
Optional (i.e. City Well No. 2)
Last Name
Company / Department / Organization
A2 Drilled For:
Sketch of Well Location
A3 Street Address of Well Location:
In sketch, indicate distances from property line,
septic field, fuel tank(s) and building.
Please include North arrow.
A4 Town / Village / Area / Lot #:
A5 UTM Coordinates (using handheld GPS):
NAD
Easting
8
3
Northing
A6 Elevation of Top of Casing:
m / ft ASL
A7 Accuracy of GPS:
+/- m / ft
A8 Purpose of Wells
Domestic
Commercial
Industrial
Zone
Test Well
Municipal
Irrigation
Observation - Water Level
Agricultural
Public/Recreational
Environmental (Quality)
Other (please identify use)
LOG OF OVERBURDEN AND BEDROCK MATERIALS (All depths are below ground surface, circle appropriate units, use descriptors provided)
EXAMPLE
ONLY
➔
(brown, grey, green, black,
redish, beige, olive, yellowish)
Depth ( m / ft )
B2 From
B3 To
CLAY, SILT, SAND, GRAVEL,
COBBLES, BOULDERS, BEDROCK
brown
SAND
B4 General Colour
B8 Permafrost Encountered:
‘trace” <10% (i.e. SILT trace gravel)
“some” 10-20% (i.e. SAND some gravel)
“silty / sandy / gravely” 20-30% (i.e. silty SAND)
“and sand” or “and gravel” 35-50%
trace gravel
B5 Most Common Material
NO
YES
B6 Secondary Materials
If yes, indicated depth ( m / ft ): from:
Y
Y
Y
M
M
D
D
Other (please specify)
Air Rotary (Conventional)
Dug
Reverse Air Rotary
Cable Tool
Mud Rotary
Auger (Hollow / Solid Stem)
( cm / in )
Steel
Plastic
Other
YG(5302)F2 Rev. 09/2006
C2 Well Type:
In what geological material is the
water producing zone located?
OVERBURDEN
Casing (depth below ground surface, please circle appropriate units)
C4 Casing Material
B7 General Description
Example:
2005 01 31
Y
C3 Outside
Diameter
soft and saturated
to:
Date Well
Completed
WELL CONSTRUCTION (Continues on Page 2)
C1 Drilling Method
some silt
MOISTURE: dry / moist / saturated (wet)
HARDNESS: soft / hard / very hard
BEDROCK
C7 Other Comments Regarding Casing:
C5 Casing Wall Thickness
( cm / in )
C6 Casing Depth to:
( m / ft )
Well Record Page 2 of 2
WELL CONSTRUCTION (Continued from Page 1)
Surface / Environmental Seal (depth below ground surface, please circle appropriate units)
C8 Seal Material Type:
C9 Diameter of Seal:
C10 Seal Depth from:
C11 Seal Depth to:
( m / ft )
( cm / in )
C12 Volume Placed:
( m3 / ft3 )
( m / ft )
(i.e. Bentonite)
Gravel Pack (depth below ground surface, please circle appropriate units)
C13 Gravel Pack:
NO
YES
If yes, indicated depth ( m / ft ):
from:
to:
Indicate diameter of material:
Well Screen Information (depth below ground surface, please circle appropriate units)
C17 Depth from:
Screen 1.
C14 Outside
Diameter
C15 Screen Material
Stainless Steel
( cm / in )
Steel
Plastic
N/A
Other
Material type:
(i.e. silica )
( mm / inches )
C16 Screen Type
Screen 2.
Continuous Wire Wrap
Screen 3.
Louver Screen
Perforated
C19 Screen
Slotted
Comments:
Open Hole
C18 Depth to:
Slot Size / Perforation Dia:
( m / ft )
( m / ft )
Thou. / mm / inches
( m / ft )
( m / ft )
Thou. / mm / inches
( m / ft )
( m / ft )
Thou. / mm / inches
WELL DEVELOPMENT AND STATUS
D1 Well Developed by
D2 Well Head Completion
D3 Well Head Stick-up
D4 Static Water Level
D5 Well Yield Estimate
(above ground surface)
(below top of casing)
Surge Block
Well House
( Lps / gpm )
Water Jetting
Pitless Adaptor Depth of adaptor:
( m / ft )
( m / ft )
Air Jetting / Air Lifting
( m / ft )
(Use negative if below grade) (Use negative if below grade)
Bailing
Well Pit (NOT PERMITTED)
Pumping
None (well not completed)
D7 Well Abandonment Status
D8 Method Used to
Other:
Estimate Well Yield
Was the well properly decommissioned
Air Lifting
D6 Final Well Status
YES
with bentonite grout?
Bailing
Abandoned
Dry
Water Supply (in use)
Not in use
NO
Pumping Test
If
well
was
If
YES,
Indicate
Date:
Stand by (Back-up)
Deepened
Poor Quality
(If test conducted, complete
abandoned, please
Pumping Test Record)
Observation
Other:
Insufficient Yield
give reason:
Artesian conditions
Y
(All depths below ground, circle appropriate units)
Y
Y
Y
M
M
D
2
2
3
3
4
4
( Lps / gpm )
min
Final Water Level (FWL)
at end of Pumping Test:
( m / ft )
G1 GROUNDWATER QUALITY
Turbidity/Sand Content
Clear
Slightly turbid/cloudy
Y
Y
Y
Y
M
M
D
Electrical Conductivity:
D
uS
Time
(min)
5
5
10
10
15
15
20
20
25
25
30
30
40
40
50
50
60
60
Bacteria Testing
Moderately turbid/cloudy
Was a sample taken?
Turbid/cloudy
Date Sample Taken:
YES
NO
If yes, indicate the
name of the laboratory.
NO
If yes, indicate the
name of the laboratory.
Trace sand present
pH:
Temperature:
Water Level
(m / ft )
1
If flowing, provide rate:
Date Measurements Taken:
Water Level
(m / ft )
1
( Lps / gpm )
Field Data
D
0 (FWL)
Duration of pumping:
hrs
D
0 (SWL)
( m / ft )
( m / ft )
M
Recomm. Pump Depth:
Recomm. Pumping Rate:
Pump Intake Set at:
M
Time
(min)
D
Static Water Level (SWL):
Y
RECOMMENDATIONS
( m / ft )
Y
Y
F1 Well Water Level Drawdown/Recovery DATA
Drawdown
Recovery
PUMPING TEST RECORD AND GROUNDWATER QUALITY
E1 Pumping Test Information
Pumping Test Start Date:
Y
Y
No sand present
˚C
Y
Y
Y
M
M
D
D
Chemical Analysis of Water
Well Disinfection
Was a sample taken?
Date Sample Taken:
Sulphur / Egg Odour
Was the well disinfected upon completion
of the pump installation?
YES
NO
Organic Taste / Odour
Briefly describe method of well disinfection.
Groundwater Type
Salty
Y
Y
Y
Y
M
YES
M
D
D
Metallic Taste
Other:
WELL CONTRACTOR
CONSULTANT (If applicable)
H1 Name of Contractor / Drilling Company:
I 1 Company Name:
H2 Name of Driller(s):
I 2 Company Address:
H3 Address of Driller:
I 3 Report Reference:
I 4 Report Date:
Signature of Primary Driller
Y
Y
Y
Y M M D
D
Date Submitted to Dept. Of Environment
ADDITIONAL INSTRUCTIONS Water Resources Section (V-310),
Upon completing this form,
please mail or fax it to:
Department of Environment,
Government of Yukon Box 2703,
Whitehorse, Yukon, Canada Y1A 2C6
Please feel free to contact us at:
Phone: (867) 667-3171, Toll free (in Yukon): (1-800) 661-0408, local 3171)
Fax: (867) 667-3195 E-mail: [email protected]
Print
Y
Y
Y
Y
M
M
D
D
Personal information contained on this form is collected under the authority of the Access to
Information and Protection of Privacy (ATIPP) Act, Section 29 (c) and will be used to compile a
public database of well and ground water information. For further information contact the
Manager of Hydrology, Water Resources at (867) 667-3223, toll free within Yukon
1-800-661-0408 Ext 3223.
I have read the above clause and
understand the purpose for
collection of personal information.
Signature of Well Owner
Clear