Mine / Project Name*

MSHA Mine ID (if applicable)

Mining Permit Number*

Regulatory Authority

Operator / Permittee Name*

Inspector Name*

Inspection Date*

Total Permit Area (acres)

Total Area Disturbed (acres)

Total Area Reclaimed to Date (acres)

Current Reclamation Phase*

Mining Status*

Grading / Backfilling Complete per Approved PlanGrading / Backfilling Complete per Approved Plan

Approximate Post-Mining Slopes

All Highwalls EliminatedAll Highwalls Eliminated

All Shafts / Adits / Voids SealedAll Shafts / Adits / Voids Sealed

Topsoil / Growth Medium ReplacedTopsoil / Growth Medium Replaced

Topsoil / Growth Medium Depth (inches)

Reclamation Phase Status Notes

Initial Seeding Date

Seed Mix Applied

Estimated Vegetative Cover (%)

Required Cover Standard (%)

Revegetation Success Status*

Noxious / Invasive Weeds PresentNoxious / Invasive Weeds Present

Soil Productivity / Capability Adequate for Postmining Land UseSoil Productivity / Capability Adequate for Postmining Land Use

Postmining Land Use

Revegetation Assessment Notes

Active Erosion Present*

Erosion Description

Sediment Basins / Ponds Functional

All Drainage Structures Intact and Flowing FreeAll Drainage Structures Intact and Flowing Free

Streams / Water Bodies Protected per PermitStreams / Water Bodies Protected per Permit

Discharge Compliance (NPDES / State Permit)

Erosion & Sediment Control Notes

Bond Release Application SubmittedBond Release Application Submitted

Bond Amount

Grading Criteria Met

Vegetation Success Criteria Met

Stream Restoration Criteria Met (if applicable)

Inspector Bond Release Recommendation*

Bond Release Notes

Outstanding Violations / NOVs on This PermitOutstanding Violations / NOVs on This Permit

Free Fillable Reclamation Inspection

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