Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • 1. Has the borehole location been established?

  • 2. Have underground utilities been cleared by third party utility locate?

  • 3. Has the Immediate Danger Zone 6-foot set back from moving and rotating equipment been measured out and marked?

  • 4. Is the ground within the 6-foot set back area free from tools, trash, heavy vegetation?

  • 5. Has the Driller ensured that no person is within the Immediate Danger zone/ exposed to entanglement hazards?

  • 6. Are all non-drilling team personnel outside of the 10-foot Exclusion Zone?

  • 7. Where rig control panels, emergency stops (kill switches), or other interfaces to control the drilling rig are within this setback barrier, can the Driller ensure that he/ she can maintain full control of the equipment while operating with 100% safety?

  • You are not cleared to drill. Take corrective action.

  • Take photo of ESTABLISHED IMMEDIATE DANGER ZONE for each borehole
  • Take a photo of the Immediate Danger Zone.

  • It is now safe to commence drilling.

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