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PERIODIC INSPECTION FORM <br />WATER, SEDIMENT, OR SLURRY IMPOUNDMENTS <br />Inspectors Name: ~ ~~~ Date: )Z- oZ- O ~F' <br />NPDES ID. No.:CO-0000213 Date Las t Inspected: ~ - q_ p <br />Facility Configuration: Total Incised Pond <br />Site Name: Impoundment #009 Location :47N16W SEC 36 <br />Mine Name: New Horizon Mine Location :l mi.NW of Nucla, CO. <br />Mine ID No.: CDMG Permit #0008-81 <br />Owners Rep.: R. L. Wade. Mine Manager <br /> CIRCLE OR WRITE IN APPROPRIATE RESPONSE <br />1. Foundation Preparation (removal of vegetal io <br />n <br />, stumps., topsoil) es No N/A <br />2. ~~ <br />ff <br />Lift thickness (inches) ~ `Z. / NcK <br />3. Compaction according to approved plan ~ No N/A <br />4. Burning (specify extend and location) Yes ~ N/A <br />5. Angle of elope: 3:1 upstream, 3:1 downstream <br />6. Seepage (specify location, color, and approx. volume) <br /> a.) From ands rdra in pipes: Yes No N/A <br /> b.) At isolated points on embankment elopes: Yes ~° N/A <br /> c) At natural hillside: Yes ~ N/A <br /> d) Over widespread areas Yes Q.*g~ N/A <br /> e) FLOm downsteam foundation area Yes ~ N/A <br /> f) "Boils" beneath at ram or ponded water Yes ~ N/A <br />7. Cracks or scarps on crest Yes ~ N/A <br />B. Cracks or scraps on elope Yes ~ N/A <br />9. Sloughing or bulging on elope Yes ~ N/A <br />10. Major erosion problems Yea ® N/A <br />11. Surface movements in valley bottom or on hillside Yes ® N/A <br />12. Erosion of toe Yes ~ N/A <br />13. water impounded against toe Yes ,~ N/A <br /> <br />14. Existing embankment freeboard (feet) ~ Feet <br />15. Cracks, bulging, or erosion on up steam face Yes N® N/A <br />16. Visible sumps or sinkholes in slurry surface Yes ® N/A <br />17. Clogging <br /> a) Spillway channels and pipes Yes ~ N/A <br /> b) Decant System Yes ~ N/A <br /> c) Diversion Ditches Yes ~ N/A <br />18. Cracking or crushing of pipes <br /> a) Spillway pipes Yes ~, N/A <br /> b) Decant system Yes ~ N/A <br />19. Trash racks clear and in place ® No N/A <br />-~ ~ s ~ ~ `k <br />[Jh <br />F:\Eng\DATA\WP\pond-banks\DAMFORM.wpd <br />~z_o7-a~' <br />