Well/Soil Boring Request Form

*Site Name

NJDEP Case No. (Project NJDEP Case No(s))

Block(s)

Lot(s)

*Site Address (street name & number)

*Site City

*Site State

*Site Zip Code

Nearest intersection (nearest cross street name)

*On-site Contact Person/Title (full name & title)

*On-site Contact Phone (include extension)

Wells Installed (total number of Wells to be installed)

Soil Borings (total number of Borings to be installed)

Est. Total Depth (Enter estimated total Depth of Wells/borings)

Casing (Casing Length)

Casing Diameter

Screen Length Interval (ie: 5-10 ft bgs)

Screen Diameter

Well Type Well TypeMonitoringDomesticIrrigationIndustrialFarmingOther

Other (enter your well use)

Slot Size

Seal Type

Well Coordinates | Northing / Easting

Coordinate System (ie: UTM)

Drilling Materials (choose from list) Drilling Materials (choose from list) Asphalt Concrete Other

Concrete (specify thickness)

Other Materials (describe)

*Requester’s Name (full name & company)

*Requester's Address (street name & number)

*Requester's City

*Requester's State

*Requester's Zip Code

*Project Manager (full name)

*Phone (include extension)

Fax

*Email Address

Site Owner Site Owner Same as Client

Owner Name (full name or company)

Owner Address (street name & number)

Owner City

Owner State

Owner Zip Code

Owner Phone (include extension)

Owner Fax

Owner Email Address

Message