Mine / Project Name*

Inspection Location / Entry*

Seam / Formation Name

Ground Control Plan Reference / Revision

Plan Row Spacing (ft)

Actual Row Spacing Measured (ft)

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*

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

Support Adequacy Notes

Immediate Roof Rock Type

Immediate Roof Rock Thickness (ft)

Main Roof / Overburden Type

Overburden Depth (ft)

Active Geological Features

Geological Conditions Notes

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

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