Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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1. Has the borehole location been established?
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2. Have underground utilities been cleared by third party utility locate?
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3. Has the Immediate Danger Zone 6-foot set back from moving and rotating equipment been measured out and marked?
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4. Is the ground within the 6-foot set back area free from tools, trash, heavy vegetation?
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5. Has the Driller ensured that no person is within the Immediate Danger zone/ exposed to entanglement hazards?
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6. Are all non-drilling team personnel outside of the 10-foot Exclusion Zone?
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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?
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You are not cleared to drill. Take corrective action.
Take photo of ESTABLISHED IMMEDIATE DANGER ZONE for each borehole
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Take a photo of the Immediate Danger Zone.
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It is now safe to commence drilling.
