**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Mine Shaft and Adit Closing (457)**

**DESIGN (911)**

**Deliverables:**

1\. Design documentation that will demonstrate that the criteria in NRCS
practice standard have been met and are compatible with other planned
and applied practices.

> a\. Practice purpose(s) as identified in the conservation plan.
>
> b\. List of required permits to be obtained by the client.
>
> c\. Impacts on adjacent properties and structures.
>
> d\. Compliance with NRCS national and state utility safety policy (NEM
> Part 503-Safety, Subpart A - Engineering Activities Affecting
> Utilities 503.00 through 503.06).
>
> e\. Practice standard criteria related computations and analyses to
> develop plans and specifications including but not limited to:
>
> i\. Structural
>
> ii\. Safety

2\. Written plans and specifications including sketches and drawings
shall be provided to the client that adequately describes the
requirements to install the practice and obtain necessary permits.

3\. Design Report and Inspection Plan as appropriate (NEM Part 511,
Subpart B Documentation, 511.11 and Part 512, Subpart D Quality
Assurance Activities, 512.30 through 512.32).

4\. Operation and Maintenance Plan

5\. Certifications that the design meets practice standard criteria and
comply with applicable laws and regulations (NEM Subpart A,
505.03(b)(2)).

6\. Design modifications during installation as required.

**[CERTIFICATION OF COMPLETION]{.underline}**

**Mine Shaft and Adit Closing (457)**

Design (911)

**[Program Participant Information]{.underline}**

Name (print):

Contract Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Contract
Item #(s):

**[Technical Service Provider Information]{.underline}**

Name (print):

TSP ID Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date:

*I hereby certify that the technical services I provided as a Technical
Service Provider for this component(s) checked above: (1) comply with
all applicable Federal, State, Tribal, and Local laws and requirements,
(2) meet applicable USDA NRCS conservation practice standards,
specifications, and program requirements, (3) are consistent with and
meet the particular conservation program goals and objectives, (4) that
I have provided the above named Program Participant the Deliverables in
this Statement of Work for this component, and (5) comply with all
"Certification Terms" as identified in the Technical Service Provider
Certification Agreement.*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Technical Service Provider Signature Date***

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Received By (NRCS staff)** **Date***

**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Mine Shaft and Adit Closing (457)**

**INSTALLATION (912)**

**Deliverables:**

1\. Pre-installation conference with client and contractor.

2\. Verification that client has obtained required permits.

3\. Staking and layout according to plans and specifications including
applicable layout notes.

4\. Installation inspection (according to inspection plan as
appropriate).

> a\. Actual materials used.
>
> b\. Inspection records

5\. Facilitate and implement required design modifications with client
and original designer.

6\. Advise client/NRCS on compliance issues with all federal, state,
tribal, and local laws, regulations and NRCS policies during
installation.

7\. Certification that the installation process and materials meets
design and permit requirements.

**[CERTIFICATION OF COMPLETION]{.underline}**

**Mine Shaft and Adit Closing (457)**

Design (911)

**[Program Participant Information]{.underline}**

Name (print):

Contract Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Contract
Item #(s):

**[Technical Service Provider Information]{.underline}**

Name (print):

TSP ID Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date:

*I hereby certify that the technical services I provided as a Technical
Service Provider for this component(s) checked above: (1) comply with
all applicable Federal, State, Tribal, and Local laws and requirements,
(2) meet applicable USDA NRCS conservation practice standards,
specifications, and program requirements, (3) are consistent with and
meet the particular conservation program goals and objectives, (4) that
I have provided the above named Program Participant the Deliverables in
this Statement of Work for this component, and (5) comply with all
"Certification Terms" as identified in the Technical Service Provider
Certification Agreement.*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Technical Service Provider Signature Date***

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Received By (NRCS staff)** **Date***

**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Mine Shaft and Adit Closing (457)**

**CHECK OUT (913)**

**Deliverables:**

1\. As-Built documentation.

> a\. Extent of practice units applied
>
> b\. Drawings
>
> c\. Final quantities

2\. Certification that the installation meets NRCS standards and
specifications and is in compliance with permits (NEM Subpart A,
505.03(c)(1)).

**[CERTIFICATION OF COMPLETION]{.underline}**

**Mine Shaft and Adit Closing (457)**

Design (911)

**[Program Participant Information]{.underline}**

Name (print):

Contract Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Contract
Item #(s):

**[Technical Service Provider Information]{.underline}**

Name (print):

TSP ID Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date:

*I hereby certify that the technical services I provided as a Technical
Service Provider for this component(s) checked above: (1) comply with
all applicable Federal, State, Tribal, and Local laws and requirements,
(2) meet applicable USDA NRCS conservation practice standards,
specifications, and program requirements, (3) are consistent with and
meet the particular conservation program goals and objectives, (4) that
I have provided the above named Program Participant the Deliverables in
this Statement of Work for this component, and (5) comply with all
"Certification Terms" as identified in the Technical Service Provider
Certification Agreement.*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Technical Service Provider Signature Date***

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Received By (NRCS staff)** **Date***

**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Mine Shaft and Adit Closing (457)**

**REFERENCES**

-   WI NRCS Field Office Technical Guide (eFOTG), Section IV,
    Conservation Practice Standard 457, Mine Shaft and Adit Closing.

-   NRCS National Engineering Manual (NEM).

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-   NRCS National Environmental Compliance Handbook

-   NRCS Cultural Resources Handbook