SOIL BORING / WELL ABANDONMENT
MONITORING WELL INFORMATION

CONTACT INFORMATION
Name:   
E-Mail Address:   
Consulting Firm:   
Contact (Project Manager):   
Phone#:
 
Fax #:
 
Consultants Project#:   
SBI Project#:   
Date Sent:   



LOCATION INFORMATION
NOTE: Location and nearest corner MUST be given to Garden State Utility Markout Service at 1-800-272-1000; 72 hours prior to work start to obtain M/O # 
Name of Property Owner:
Address of Property Owner:
City:  State: 
County:  Zip: 
Name of Site/Facility:
Address of Site/Facility:
City:  State: 
County:  Zip: 
Lot:  Block: 
Site Map Attached?  Yes  No
Longitude:  Lattitude: 
NJDEPE Case?  Yes  No
Type of Case:  Case #: 



SOIL BORING(S) INFORMATION
Drilling Method: 
# of Locations: 
Est. Depth: 
Material Expected to be Encountered:



MONITORING WELL(S) INFORMATION
Drilling Method: 
# of Locations: 
Est. Depth: 
Riser Material: 
Diameter: 
Screen Material: 
Slot Size: 
Material Expected to be Encountered:



SAMPLING INFORMATION
Sampling Method: 
# of Locations: 
Interval: 
Diameter: 
Provide Sample Bottles?:  Yes  No
Est. # 



WELL ABANDONMENT
Total Depth of Well: 
Casing Length: 
Diameter: 



DECONTAMINATION INFORMATION
Decontamination?:  Yes  No
Method Required: 
Drill Rig: 
Sampling Equipment: 



ADDITIONAL SERVICES
Well Development?  Yes  No # of Locations: 
  Greatest Depth: 
Dedicated Piping?  Yes  No
Approx. Amt. Required: 
Provide Drums?  Yes  No # of Drums: 



NOTES: