Closed Loop Heat Pump System with Ten or More Boreholes
-2540000NDEE Water Well Standards PO Box 98922Lincoln, NE 68509-8922Phone: 402-471-0546Email: NDEE.waterwellstandards@Please Type or Print ClearlyPRE-NOTIFICATION FORMCLOSED LOOP HEAT PUMP SYSTEM WITH TEN OR MORE BOREHOLESWell Owner Name_________________________________________Well Owner Address_________________________________________Well Owner Email_________________________________________County_________________________________________Legal Description_________________________________________Physical Address_________________________________________GPS_________________________________________Test Hole Log Information (attach if available)_________________________________________Estimated Bore Depth _____________ FeetEstimated Bore Diameter _____________ InchesGrout from ___________ to ___________Grout Material _____________________________Pipe Outside Diameter _________________ Inches Pipe Material ______________________________Static Water Level ______________ Feet (measured/approximate)Water Well Contractor Name_________________________________________Water Well Contractor Signature _________________________________________Date _____________________________________Water Well Contractor Email_________________________________________Water Well Contractor License No. _____________System Installer Name (if different) _________________________________________System Installer Signature (Header Piping, Circulating Fluid)_________________________________________Date _____________________________________Estimated Date Drilling Commenced _________________________________________Estimated Completion Date _________________________________________Well Owner Signature_________________________________________Date _____________________________________Distance from PWS Well _______________ FeetDistance from Sewer Line ________________ FeetNumber of Boreholes _______________________Closed Loop Length __________________ FeetLoop Fluid ________________________________Pressure Test ___________ PSI ___________ Min ................
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