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Mining Form

Free Fillable Ground Control Inspection

Fill out this ground control inspection online and download as PDF - free, no signup required.

MI-0639 fieldscompliance

Project Information

Project Information

Mine / Project Name*

MSHA Mine ID*

Inspection Location / Entry*

Inspector Name*

Inspection Date*

Inspection Time

Seam / Formation Name

Ground Control Plan Reference / Revision

Roof Bolt Pattern & Spacing

Roof Bolt Pattern & Spacing

Bolt Type*

Bolt Length (ft)

Bolt Diameter (in)

Plan Row Spacing (ft)

Actual Row Spacing Measured (ft)

Plan Bolts per Row

Actual Bolts per Row

Plan Bolt Spacing (ft — center to center)

Actual Bolt Spacing Measured (ft)

Torque / Tension Testing PerformedTorque / Tension Testing Performed

Bolt Pattern Compliant with Plan*

Bolt Pattern Notes

Support Adequacy Rating

Support Adequacy Rating

Overall Support Adequacy Rating*

Standing Supports Present (Timbers, Cribs, Packs)Standing Supports Present (Timbers, Cribs, Packs)

Straps / Roof Mats / Mesh Installed per PlanStraps / Roof Mats / Mesh Installed per Plan

Pillar Conditions

Support Adequacy Notes

Geological Conditions

Geological Conditions

Immediate Roof Rock Type

Immediate Roof Rock Thickness (ft)

Main Roof / Overburden Type

Overburden Depth (ft)

Active Geological Features

Fault / DykeRoll / HorsebacksSlickensidesFracture / Cleat SystemWater / SeepingSandstone Channel / WashoutNone Observed

Geological Conditions Notes

Supplemental Support Needs

Supplemental Support Needs

Supplemental Support RequiredSupplemental Support Required

Supplemental Support Notes

Area Evacuated Pending Ground Control ActionArea Evacuated Pending Ground Control Action

Ground Control Plan Revision NeededGround Control Plan Revision Needed

Corrective Action Deadline

Photos

Photos

Location

Location

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