FIELD INSPECTION REPORT Project Name

Quality Control Form Project No.:

BOREHOLE DRILLING ITP NO.:
SITE WORK CHECKLIST Report No.:

Inspector Name: Project Manager

Inspector No.: Project Mgr. No.:
Date Project Owner
Work No.: Item No.: Location:

1. SITE LOCATION
Is the drilling location adequately isolated from sources of contamination YES NO N/A
Does the location comply with permit conditions? YES NO N/A
Will the borehole be accessible for maintenance? YES NO N/A
Is the borehole in a nonflooding location? YES NO N/A
2. DRILLING METHOD
What type of drilling method is being used?
3. BOREHOLE RECORDS
Is the borehole driller routinely checking cuttings samples and recording geologic YES NO N/A
information?
4. BOREHOLE CONSTRUCTION DETAILS
Type: Sand or Gravel (unconsolidated) Bedrock (consolidated)
Grouting:
a. Type Manufacturer Product Name
b. Is the mud scale used to weigh grout?
c. What grouting method will be used?
d. Are all necessary grouting equipment (mixer, pump, grout pipe, hoses) and YES NO N/A
materials at the drilling site?
e. Did grout appear at the wellhead after pumping? YES NO N/A
f. If the borehole casing is driven (cable tool, jetting, hollow rod), is dry granular YES NO N/A
bentonite placed around the casing during driving?
5. BOREHOLE CASING
Type of well casing: PVC Galvanized steel Black steel Other :
Casing material approved? YES NO N/A
7. BOREHOLE SCREEN
Type of screen: PVC Stainless steel Other:
Installation method: telescoped attached to casing
Filter-pack installed? YES NO N/A
Filter-pack chlorinated? YES NO N/A
8. DRILLING WATER
Source approved? YES NO N/A
Drilling water chlorinated to at least 10 ppm residual? YES NO N/A
9. BOREHOLE DEVELOPMENT

Development method used: air surge block bailer plunger water jetting overpumping
Approximate borehole capacity (per minute):
Water free of sand or other turbidity upon completion of the development? YES NO (Check
N/A with clean
10. BOREHOLE DISINFECTION
Borehole disinfected upon completion? YES NO N/A
Method and amount of disinfectant adequate? YES NO N/A
Final chlorine residual in well ppm (Check w /chlorine test strips):
11. APPROVED CAP? YES NO N/A

Comments: