The path to better gold mining practices in Latin America and the Caribbean (LAC) is rife with challenges due to the complex linkages between the high value intensity of gold, its spatial concentration in specific geological formations, and the social and economic conditions that render it one of the most financially attractive yet damaging land use activities in the region. Its uncontrolled spread across many lowland river basins of LAC continues to leave a record of significant environmental impacts, cultural change, social unrest, and human health concerns. At its best, however, the mining sector can play a significant role in the near-term development of regional economies by boosting employment, increasing public revenues, supporting business growth, and building public-purpose infrastructure, such as roads and power facilities. But over the long term, poorly managed and regulated mining can create significant environmental and social costs that are simply passed on to future generations. This is the case in particular when proceeds from mining are not effectively reinvested by governments in improving social and environmental conditions. This paper provides a brief overview of the linkages between the primary factors driving gold mining, how these interact with regional geology to concentrate impacts on specific river basins, and the primary environmental and social impacts that can erode the economic benefit delivered from gold production if it is left unmanaged. We consider these impacts in the context of operational scale and the regional differences in background hydrological conditions with a view to identifying freshwater systems that are most inherently vulnerable to the effects of mining and that thus have the greatest impact of additionality. The paper concludes by considering ways in which these impacts might be averted or mitigated through a mix of approaches aimed at normalizing mining processes, structures, and relationships through tailored, incentive-based policies and actions.