Closed Loop Well System Construction Report

2. 310 E. Torrance Avenue, Pontiac, Illinois 61764
   
4. CLOSED LOOP WELL SYSTEM CONSTRUCTION REPORT

   Complete and Submit Within 30 days of Geothermal Well Completion

6. Contractor
7. Property Owner
9. Registration Number
10. Phone Number
11. Jobsite Address
13. Drill Operator
14. City, State, Zip Code
16. Well Completion Date
17. Number of Holes
18. Owner Phone Number
20. Depth of Boreholes
21. HVAC Contractor (if different from above)
23. Diameter of Holes
24. Size of Pipe/DR
25. Name
26. Phone Number
28. Piping from header to building: Size of Pipe/DR
29. Antifreeze Installed By

    1. Driller
    2. HVAC Contractor
31. Trace Wire/Locators Used?

    1. Yes
    2. No
32. Antifreeze Type and Percentage
36. DRILL LOG
38. FROM
39. TO
40. FORMATION
42. FROM
43. TO
44. FORMATION
46. FROM
47. TO
48. FORMATION
50. FROM
51. TO
52. FORMATION
54. FROM
55. TO
56. FORMATION
58. FROM
59. TO
60. FORMATION
62. FROM
63. TO
64. FORMATION
68. Grout Information

    1. Bentonite
    2. Enhanced
    3. Graphite
70. Bentonite:
71. Number of batches per hole
72. Lbs per batch
74. Sand:
75. Number of batches per hole
76. Lbs per batch
78. Graphite:
79. Number of batches per hole
80. Lbs per batch
82. Plugs Used?
    -- Select One --YesNo
83. Method:

    1. Tremie Pipe
    2. Other
84. If Method is "Other", Explain:
86. System Location
87. GPS Coordinate W
88. GPS Coordinate N
90. Variance Obtained for this jobsite?
    -- Select One --YesNo
91. Was There any deviation from the permit application for this jobsite?
    -- Select One --YesNo
93. Explain (attach drawing when needed)
95. Contractor's Signature
96. Date
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit Submit and Print

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