Cemented waste rock backfill (CWRB), which is a mixture of tailings, waste rock, cement, and water, is subjected to combination actions in underground mining operations and has been widely used in deep resource mining. While the strength requirement and macroscopic deformation behaviors of CWRB have been well studied, the mesoscopic damage evolution mechanisms are still not well understood. In this work, a CWRB sample with a waste rock proportion of 30% was studied with a uniaxial compression test under tomographic monitoring, using a 450 kV industrial X-ray computed tomography (CT). Clear CT images, CT value analysis, crack identification, and extraction reveal that CWRB damage evolution is extremely inhomogeneous and affected by the waste rock size, shape, and distribution. Furthermore, the crack initiation, propagation, and coalescence behaviors are limited to the existing waste rocks. When deformation grows to a certain extent, the cracks demonstrate an interlocking phenomenon and their propagation paths are affected by the waste rocks, which may improve the ability to resist compressive deformation. Volumetric dilatancy caused by the damage and cracking behavior has closed a link with the meso-structural changes, which are controlled by the interactions between the waste rocks and the cemented tailing paste.