Monitoring Well Completion Form
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1Illinois Environmental Protection Agency
Well Completion Report
Site Number: __________________________
County: __________________
Well #: _____________
Site Name: ___________________________________________________________
State
o
'
"
o
'
"
Borehole #: __________
Plane Coordinate: X _____ Y _____ (or) Latitude: ____ ____ ____ Longitude: ____ ____ ____
Surveyed by: ______________________________________
IL Registration #: _______________________________
Drilling Contractor: _________________________________
Driller: ________________________________________
Consulting Firm: ___________________________________
Geologist: ______________________________________
Drilling Method: ___________________________________
Drilling Fluid (Type): _____________________________
Logged By: _______________________________________
Date Started: ____________ Date Finished: ___________
Report Form
Date: _____________________
Completed By: _____________________________________
ANNULAR SPACE DETAILS
Elevations
Depths
(.01ft.)
(MSL)*
(BGS)
______
_______
Top of Protective Casing
______
_______
Top of Riser Pipe
Type of Surface Seal: __________________
______
_______
Ground Surface
______
_______
Top of Annular Sealant
Type of Annular Sealant: _______________
Static Water Level
Installation Method: _________________
______
_______
(After Completion)
Setting Time: ______________________
Type of Bentonite Seal - - Granular, Pellet, Slurry
______
_______
Top of Seal
(Choose One)
Installation Method: _________________
______
_______
Top of Sand Pack
Setting Time: ______________________
______
_______
Top of Screen
Type of Sand Pack: ____________________
______
_______
Bottom of Screen
Grain Size: _______ (Sieve Size)
______
_______
Bottom of Well
Installation Method: ________________
______
_______
Bottom of Borehole
* Referenced to a National Geodetic Datum
Type of Backfill Material: ______________
(if applicable)
CASING MEASURMENTS
Installation Method: _________________
Diameter of Borehole (inches)
ID of Riser Pipe (inches)
WELL CONSTRUCTION MATERIAL
Protective Casing Length (feet)
(Choose one type of material for each area)
Riser Pipe Length (feet)
Bottom of Screen to End Cap (feet)
Protective Casing
SS304, SS316, PTFE, PVC, or Other
st
Screen Length (1
slot to last slot) (feet)
Riser Pipe Above W.T.
SS304, SS316, PTFE, PVC, or Other
Total Length of Casing (feet)
Riser Pipe Below W.T.
SS304, SS316, PTFE, PVC, or Other
Screen Slot Size **
Screen
SS304, SS316, PTFE, PVC, or Other
**Hand-Slotted Well Screens are Unacceptable
Well Completion Form (revised 02/06/02)
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