Manual 2100-583G
Page
47 of 48
DATE
TAKEN BY:
1. Unit Manufacturer ________________
Model No. ________________
Serial No. _________________
Thermostat Manufacturer __________________
Model No. _________________
2. Company Reporting _______________________________________________________________________
3. Installed by ___________________________________________________ Date Installed ____________________
4. User's (Owner's) Name ___________________________________________________________________________
Address________________________________________________________________________________________
________________________________________________________________________________________
5. Unit location ___________________________________________________________________________________
WATER SYSTEM INFORMATION
6. Open Loop System (Water Well) _____________ Closed Loop System ________________
A. If Open Loop, where is water discharged ?____________________________________________________
7. The following questions are for Closed Loop systems only!
A. Closed Loop system designed by: ______________________________________________________
B. Type of Antifreeze used __________________________________ % Solution __________________
C. System Type: Series __________________ Paralled ____________________
D. Pipe Material ____________________________ Nominal Size ______________________________
E. Pipe Installed:
1. Horizontal _____________________ Total Length of Pipe _________________ ft.
No. Pipe in Trench ________________ Depth bottom pipe ___________________ ft.
2. Vertical _______________________ Total depth of bore hole _______________ ft.
GROUND SOURCE HEAT PUMP
PERFORMANCE REPORT