MONITORING WELL CONSTRUCTION FORM Well Name:

MONITORING WELL CONSTRUCTION FORM
Route To:
Solid Waste
Other:
Facility/Project Name:
GWIC Well ID.:
Well Name:
Well GPS Location (NAD 83): Lat.:
Facility License Number:
Well Location:
¼,
¼, Sec
(legal description to nearest ¼. ¼ section)
Date Well Installed:
Long.:
,T
Type of Well:
Ground Water Monitoring
Piezometer
RPOC
,R
Location of well relative to waste source:
Upgradient
Downgradient
Side-gradient
Distance from waste source boundary:
Well Installed By: (name and company)
First Name:
Last Name:
Unknown
Well Constructor License Number:
Company Name:
1. Cap and lock?
A. Protective pipe, top elevation:
.
B. Well casing, top elevation:
C. Land Surface Elevation:
ft. MSL
.
D. Surface seal, bottom:
ft. MSL
.
ft. MSL
.
ft. MSL
No
2. Protective cover pipe:
a. Inside diameter:
b. Length:
.
.
in.
ft.
c. Material: Steel
12. USCS classification of soil near screen:
Other:
GP
GM
GC
GW
SP
SM
SC
SW
ML
MH
CL
CH
Bedrock
3. Surface seal: Bentonite
Concrete
Other:
4. Material btw. well casing and protective pipe:
13. Sieve analysis attached? Yes
No
Bentonite
14. Drilling method used: Rotary
HSA
Other:
Other:
Annular space seal
5. Annular space seal:
15. Drilling fluid used:
Water
Yes
Air
a. Granular benonite
Drilling Mud
16. Drilling additives used? Yes
None
No
Specify:
17: Source of water:
E. Bentonite seal: top
F. Fine sand: top
G. Filter pack: top
.
.
ft. MSL
b.
lbs/gal mud weight….bentonite/sand slurry
c.
lbs/gal mud weight….bentonite slurry
d.
% bentonite ……….bentonite/cement grout
e.
ft volume added for any of the above
3
f. How installed: Tremie
ft. MSL
.
ft. MSL
6. Bentonite seal: Bentonite granules
¼ in.
H. Screen joint: top
.
I. Well bottom: top
ft. MSL
.
ft. MSL
J. Filter pack: bottom
.
Tremie pumped
Gravity
3/8 in.
½ in. Bentonite pellets
Other:
7. Fine sand material: (Manufacturer, product name, mesh size)
ft. MSL
Volume added:
K. Borehole: bottom
.
L. Borehole diameter:
.
M. O.D. well casing:
N. I.D. well casing:
ft. MSL
.
.
in.
in.
in.
ft
3
8. Filter pack material: (Manufacturer, product name, mesh
size)
Volume added:
ft
3
9. Well casing: Flush-threaded Sch 40 PVC
Flush-threaded Sch 80 PVC
CERTIFICATION:
I hereby certify that the information on this form is true
and correct to the best of my knowledge:
Other:
10. Screen material:
a. Screen type: factory cut
continuous slot
Other:
(Signature)
b. Manufacturer:
c. Slot size: 0.
(Company Name)
d. Slotted length:
11. Backfill material:
in.
.
ft.
or None