/ Health & Safety
Pre work
Questionnaire
This information is provided by………………………………………………………………………… (the “Consultant”) to enable Exploration Ltd (the “Contractor”) to fulfil its statutory obligations under the Health & Safety at Work Act 1974 and COSHH Regulations 1994.
1.  ADDRESS & NATURE OF THE SITE (Including postcode)
Location:…………………………………………………………………………………………………….
Can the Consultants provide a map showing access routes? (Please attach) / YES / NO
Nature of Site. (E.g. Landfill, Derelict Factory etc.)…………………………………………………………………
Probable geology of site if known:……………………………………………………………………………
Are there any access problems on site i.e. gypsy bunds, locked gates, rough ground
…………………………………..………………………………………………………………………………………..
Specify the time & date you require our drillers to be on site ?......
2.  NATURE OF WORK TO BE UNDERTAKEN
The Consultant requires the Contractor to carry out the following type of work: (tick if required)
Coring using the drilling rig / Breaking out using the drilling rig / Soil Sampling (Windowless) / Hand dug Trial Pits to 1.2m.
Other Please specify below / Dynamic Probing
(Super Heavy as standard) / Hand Held sampling / SPT Testing
......
Number of Boreholes required...... Depth of Boreholes......
Number of Dynamic Probes...... Depth of Dynamic Probes......
3.  MONITORING WELL INSTALLATION DETAILS
Number of Installations required PLEASE PLACE A NUMBER IN THE BOXES OPPOSITE / No.: / Amount of plain pipe required (i.e. 1m per well)
Size: / 50 mm / 35 mm / 25 mm / No......
Do you require well sock ?………………..... Do you require Raised covers......
4.  ACTUAL & POTENTIAL HAZARDS

N.B. Competitor Rig requires 3.2 m Height/ 0.75- 0.9m m Width clearance and 2.64 m Length to operate, Please ensure there are correct clearances

/ YES / NO
Has the Consultants carried out a desktop study of the site?
Has the Consultant carried out a site walkover / Risk Assessment?
Has the Consultant obtained plans of underground services?
Has the Consultant checked borehole locations with Cable and Pipe Locating Devices?
Has the Consultant arranged for a service scan by a third party?
Is there likely to be methane or other flammable/explosive gases on the site?
Is the consultant aware of any specific hazards (e.g. asbestos, corrosive or carcinogenic substances, Heavy Traffic, Confined spaces?)
If Yes, what specific hazards have been identified?……………………………………………….……………….
……………………………………………………………………………………………………………………………
How does the Consultant categorise the site? / GREEN / YELLOW / RED
5.  SAFETY EQUIPMENT AND INFORMATION
Exploration Ltd will provide its personnel with the following Personal Protective Clothing (PPE) as standard:
·  Hi Vis Clothing, Safety Footwear, Hard Hat, Gloves, ear protection.
Please indicate whether any of the following will be required on this site:
YES / NO
Dust Masks (Disposable)
Disposable Overalls & Gloves
Eye Protection
Will the Consultant provide additional specialised PPE if required
Will appropriate hygiene facilities be available on site?
Will a jet wash facility be available on site if required?
6.  ADDITONAL EQUIPMENT REQUEST (ADDITONAL COST INVOLVED)
Tick if you require any of the following
Ventilation Fan...... Ducting in 20m Lengths No......
110v Lighting towers...... Road Barriers......
Wet Vac...... More than 4m Casing when Drilling......
Separate coring rig...... Separate breaker & power pack......
7.  ADDITONAL INFORMATION
Is there a water source on site
Use the space below to provide any relevant additional information that you think may be relevant to the works being undertaken:
8.  LIABILITY FOR DAMAGE TO SERVICES
Exploration Ltd will conduct borehole drilling in the precise locations as instructed by the consultant. The Consultant is responsible for ensuring that drilling in these locations will not interfere with any underground services by commissioning a third party to carry out “Clearance Surveys” or by providing plans and pre marking all drilling positions.
·  Services located by Third Parties:
The Consultant agrees to hold Exploration Ltd free from any claims for damages to services or any consequential damages, caused as a result of following the Consultant’s instructions.
It is expected that all third party clearences will be carried out in a professional manner and that these companies will be fully insured for the service provided and take full responsibility for clearing locations.
9.  CONSULTANTS ACCEPTANCE
Please sign below to show that the information you have provided is to the best of your knowledge true and correct, and that you accept the terms and conditions of Exploration Ltd.
NAME
(IN BLOCK LETTERS) / ……………………………………………………………………………
SIGNATURE / ……………………………………………………………………………
POSITION / ……………………………………………………………………………
DATE / ……………………………………………………………………………
Name & Mobile No of Engineer to be on site.
State none if applicable / ……………………………………………………………………………

H&s vrsion 1 3