Appendix F

Lifewater Canada Well Record line

Well Location
Country: Location Sketch



Site Description:

Distance to nearest pollution sources (ft) - describe:

Soil Type
Drilling Notes
(Drilling Speed, bit vibration, water temperature etc)

Depth at which water encountered:

Depth to Water Table:

Depth of Borehole:

Borehole Yield
Yield: Duration of Test (minutes):
Describe how yield measured:

Well Screen & Casing
Material (PVC, Other): Casing/screen diameter:
Thickness (Schedule 40 or 80): Length of screen sump:
Number of slot columns: Vertical spacing between slots:
Length of slots: Screen Length:
Installed length of casing: Total length of screen/casing:
Describe screen centralizers (number, where/how attached):

Describe drive shoe (shape, material, size etc):

Well Completion
Gravel pack material diameter (inches): Gravel pack volume:
Type of stabilizer material: Stabilizer material volume:
Grout mix (sand:cement ratio): Grout volume:
Pad concrete mix (sand:gravel:cement): Thickness of cement pad:
Size of cement pad: Well protected by fencing (Y/N):
Distance from ground to pump cylinder: Cylinder diameter:

Well Development
Technique Used: Development Time (hours):
Describe process (turbidity in discharge water over time and depth):

Type of chlorine used: Volume of chlorine used:
Length of disinfection period: Chlorine odour in discharge water (Y/N):
Describe how chlorine was mixed with well water:

Water Quality
Colour: Turbidity:
Odour: Taste:
Bacteria test type: Bacteria Test Results:
Other tests or characteristics (pH, Total Dissolved Solids, nitrate, staining etc):

Completed Well Performance
Piston clearing cylinder top&bottom (Y/N): Waste water drainage:
Sustainable pumping rate (Gal/min): Pump stable:
Other (cylinder secured with safety rope? etc):

Date Drilling Started:

Date Work Completed:

Number of Workers:

Construction Foreman's Name (Print):

Foreman's Signature:

Action Agency/Lifewater Inspector Confirmation

Name (Print):


Inspection Date:

Well Record Copies:
1) Lifewater Canada
2) Local Drill Team
3) Local Government

PHOTOGRAPHS: (Well Overview Required. Pump close-up, Surroundings, People Desirable)

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