Microsoft Word - Geothermal Closed-Loop Construction ...
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Installation Site Information
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY WATER BUREAU
GEOTHERMAL CLOSED-LOOP CONSTRUCTION NOTICE
Property Tax. No. County Township
Latitude Longitude Permit Number
Distance & Direction from Nearest
Road Intersection
Street Address, City/Zip
Section Town No. Range No. Intended Date of Installation
Property Owner
Address
City/Zip
Owner Address Same as Loop Address? Yes No
Facility Type
Residential Commercial
Industrial Other
Type of building/business
Proposed Site Sketch
Heat Exchanger Type
Vertical lineal feet Horizontal lineal feet _ Pond lineal feet _
Number of *
Vertical Loops
Loop Joining Method Heat Fusion Joint Electrofusion Joint Other
Closed-Loop Installer
Vertical Loop Piping Dimensions *
Diameter in. to ft. depth
Vertical Loop Bore Dimensions *
Diameter in. to ft. depth
Show proposed location of vertical or horizontal loop relative to buildings and other structures or landmarks on the site. Include a north arrow.
_
Business Name License No.
Address
City/State/Zip
Phone Number Email
Individual Completing Notice Property Owner Installer
Phone Number Email
(Separate site sketch may be attached.)
Signature Date
Submit above information BEFORE installation – Submit below information & final site sketch on other side AFTER installation.
Date of Installation
/ / Pressure Testing of
Completed Loop
psi min
Number of Bags of Grout *
Borehole Grouting Material
Thermal Enhanced Bentonite Slurry
Bentonite Slurry
Thermal Enhanced Cement
Neat Cement
Concrete
Formation Description *
Note: Completion required for vertical boreholes only.
Thickness
of Stratum *
Depth to * Bottom of Stratum
Heat Transfer Fluid Percent Solution Volume: Type: in Water:
_%. gal.
Loop Field Latitude & Longitude Note: For a loop field, please enter the latitude and longitude for all four corners of the field here:
NW corner: Lat _ _ Lon NE corner: Lat_ _ _ Lon SE corner: Lat_ _ _ Lon SW corner: Lat_ _ _ Lon
Business Name License/Reg. No.
Address
City/State/Zip
Use 2nd Sheet if Needed
ATTENTION PROPERTY OWNER: FILE WITH DEED
Complete Final Site Sketch on Other Side
EQP 5962
Note: Sections marked with an asterisk (*) are not required to be completed for horizontal closed-loop systems.
Final Site Sketch (Top View)
Show final location of vertical or horizontal loops with measured distances to permanent structures, driveways, property lines, and buried pipes and utilities.
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Cross Section Sketch
Show cross section of vertical, directionally-bored or angle drilling loops with length or depth of borings, degrees of angle from horizontal, and distance from end of borings to property lines.
GROUND SURFACE
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