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National Rural Infrastructure Development Agency Ministry of

Rural Development, Government of India Template Version : V3.0

Form Id 39250 Format QR Version 2021.0- Part I

Format for information to QM for Inspection of Ongoing/Completed Work

PART I– Work Information (To be filled-up by PIU)

1. GENERAL:

I. Work is: ✔ Ongoing Completed

II. Current stage of work: Stage-I Stage-II ✔ Complete

III. Date of inspection:

NQM Code
IV. Name of Quality Monitor (QM): Pradeep Chandra Mandal
✔ SQM Code

V. State: Odisha District: Sambalpur Block: Bamra

VI. Name of Road: MRL09-Bamra to Uchhakpat Via Kechupani and Bhogapada

VII. Package Number: OR28305

VIII. Sanctioned length: 3.640 km, Flexible pavement: 3.25 km,Rigid/Semi-Rigid pavement: 0.39 km

IX. Executed length: 0 km, Flexible pavement: 0.000 km, Rigid/Semi-Rigid pavement: 0.000 km
(in case of completed works only)

X. Reasons for deviation (if any): N/A

XI. Name of new technology (if used) N/A

Select new technology used RD from km to km

Select new technology used RD from km to km
Select new technology used RD from km to km

XII. Estimated cost (as cleared by GOI): Rs. 206.66 Lakh

XIII. Technical sanction cost: * Rs. 181.66 Lakh

XIV. Awarded cost: Rs. 169.45 Lakh

XV. Expenditure: (if work is ongoing)

a. Expenditure done: Rs. 0.00 Lakh

b. Bills pending:* Rs. 18.50 Lakh

Total expenditure (a+b) *

Rs. 18.50 Lakh

XVI. Completion cost: (if work is completed) Rs. Lakh

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XVII. The work is a case of (check✓boxes as applicable)

A) New Connectivity Total length: km

(i) Carriageway width (m): 3m 3.75m 5.5m 7m

B) ✔ Up-gradation Total length: km

(i) Carriageway width and length:

Existing width m
With widening Length km
Proposed width m

Without widening Proposed width m Length km

XVIII. Terrain: (check ✓ anyone box) Plain Rolling ✔ Hilly Steep

XIX. Date of award of work: (date/ month/ year) 27/06/2022

XX. Date of start of work:(date/ month/ year) 27/06/2022

XXI. Stipulated date of completion:(date/ month/ year)

26/03/2023

XXII. Actual date of completion: (date/ month/ year)

(in case of completed work)
2. PHYSICAL PROGRESS: (Ongoing/Completed)*
I. Construction Programme and Physical Progress:
Item of work Unit Quantity Quantity Completed Fill in start and completion dates Delay in
(length/ As per executed percentage months
number) DPR of item Progress Start Completion
status Date Date
(1) (2) (3) (4) (5) (6) (7) (8) (9)
Due 04/07/2022 30/07/2022
✔ i) Preparatory Work Km 3.640 3.64 100.00
Actual 11/07/2022 30/07/2022
0

ii) Earth Work& Due 01/08/2022 30/10/2022

✔ Km 3.25 0.000 0.00 0
Subgrade Actual 10/08/2022
Due 30/07/2022 30/09/2022
✔ iii) CD Works No's 4.000 0.000 0.00
Actual
Due 30/07/2022 30/09/2022
✔ iv) Protection works m 88.000 0.000 0.00
Actual
Due 01/08/2022 01/10/2022
✔ v) Sub Base including Km 3.25 0.000 0.00
shoulders Actual
vi) WBM/ WMM Base Due 01/08/2022 01/10/2022
✔ Km 3.25 0.000 0.00
Course Actual
vii) Bituminous Due 01/09/2022 20/05/2023
✔ Base/Wearing Km 3.25 0.000 0.00
Actual
Course
viii) Bituminous Surface Due 15/09/2022 20/05/2023
✔ Course Km 3.25 0.000 0.00
Actual
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Due 04/07/2022 03/09/2022
✔ ix) CC Pavement Km 0.390 0.200 51.28 1
Actual 22/08/2022
Due 04/07/2022 11/07/2022
✔ x) Signage etc. No's 5.000 0.000 0.00 0
Actual 04/07/2022

3. QUALITY CONTROL:
I. Location of field laboratory: * Tape Para Ch-1/800 km

II. Geo-tagged photograph of laboratory uploaded on: (date/ month/ year) * 19/08/2022

III. Reason for delay in establishment of field laboratory(if so): N/A

IV. Details of contractor, executing the work: *

Name of contractor PAN number Mobile number E-mail ID.

✔ Padmanav Purohit AOXPP1231P 9777366933 padmanavpurohit@gmail.com

V. Details of contractor’s engineer available at site: (Responsible for maintaining quality control register part-1) *
Sl. Name of contractor’s Duration of posting at site
no. Identity number Mobile number
engineer at site From To
✔ 1 Tanmaya Kumar Mishra 8 8249463109 22/06/2022 30/07/2022
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VI. Details of contractor’s lab technician: *
Sl. Name of contractor’s Duration of posting at site
no. Identity number Mobile number
lab technician From To
✔ 1 Ashok Kumar Sethy 10 8596952324 20/02/2022 22/06/2023
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VII. Details of Head of PIU supervising the work: *
Sl. Head of PIU Duration of posting at site
no. Employ number
(Executive engineer) From To
✔ 1 Ramesh Chandra Jalli 66001134 09/06/2022 22/06/2023

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*
VIII. Details of Assistant engineer supervising the work and maintaining quality control register Part-II:

Sl. Duration of posting at site

Name of Assistant
no. Employ number Mobile number
engineer From To
✔ 1 Rajanikanta Munna 91147287 9438289663 07/06/2022 22/06/2023
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IX. Details of the Junior engineer supervising the work: *

Sl.
Name of Junior Duration of posting at site
no. Employ number Mobile number
engineer
From To
✔ 1 Ramakanta Dubey 91445358 9437714438 27/06/2022 26/06/2023
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X. List of equipments available in field lab:* Core cutter 01 set

Sieve 01 set, Standard Proctor Density 01 set, Oven 01 no,

Table (IX) a Sand replacement 01 set

Available equipments that are in working condition Available equipments that are not in working
(1) * condition (2)*
All equipments are in working condition N/A

XI. List of equipments not available in field lab:* N/A

XII. Reasons put forth by PIU for non availability of equipments in field lab:
N/A

XIII. Equipments and documents ready to be made available to QM before or during the inspection:*
Equipments mentioned in the item no.10 and all documents like agt, DPR, Estimate QCR part-1 and 2 etc are ready to be
made available to QM

4. DETAILS OF MIX DESIGN(s) (if provided in the sanctioned project):

(Manadatory in case of “Yes”)
If applicable (check✓ the box) Yes ✔ No

Sl. Mix Design Institute/laboratory where mix Date

Mix Design
No. Strength design was done
i. Cement Concrete M20
✔ ii. Cement Concrete M 30 39.20 N/mm sqm Jharsuguda Engineering School 22/08/2022

iii. Dense Bituminous Macadam

iv. Semi Dense Bituminous Concrete
v. Bituminous Concrete
5. EARLIER INSPECTIONS BY NQM, SQM or SENIOR DEPARTMENTAL 5
OFFICERS (SEs & CEs) AND ACTION TAKEN STATEMENT:
(Details about departmental officers who inspected the work should be added after the NQM/SQM details.):

Date Name and Road distance Level of Major observations Action taken by PIU
of Designation of (RD) work at the with date
visit inspecting officer time of
(NQM/SQM/CE/ From To inspection
(1) SE)(2) (3) (4) (6) * (7) *
(5) *

Satisfactory N/A
06/07/2022 SE 0.000 3.25 Earth Work& Subgrade

Satisfactory N/A
26/07/2022 SE 0.000 3.25 CC Pavement

Ramesh Chandra jalli, Executive Engineer

Signature of the Head of PIU……………………………………….……….

Name and Designation of the Head of PIU*………………….…………….

Ramesh Chandra jalli, Executive Engineeer
Seal of PIU
* 9437562208
Mobile Number of the Head of PIU……………….……………………
eerw_kuchinda@gmail.com
E-mail of the Head of PIU……………….……………………………
Rural Works Division, Kuchinda
*
Address of the PIU…………………………………………………………..
* 25/09/2022
Date:……………………………………………………………..…………..