Minnesota Department of Health
Well Management Section
625 North Robert Street
P.O. Box 64502
St. Paul, Minnesota 55164-0502
651-201-4600 or 800-383-9808
www.health.state.mn.us/divs/eh/wells
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
MEMORANDUM
TO: Licensed Well Contractors
Licensed Bored Geothermal Heat Exchanger Contractors
FROM: Ms. Kara E. Dennis, Hydrologist
Well Management Section
625 North Robert Street
P.O. Box 64975
St. Paul, Minnesota 55164-0975
SUBJECT: Application for Installation of Bored Geothermal Heat Exchanger
The application form for a permit to install a bored geothermal heat exchanger (earth-coupled
heat loop) is attached.
Please send the completed application form along with the fee and required documentation to:
Well Management Section
Environmental Health Division
Minnesota Department of Health
P.O. Box 64502
St. Paul, Minnesota 55164-0502
The permit application fee is:
Bored Geothermal Heat Exchanger Permit < 10 tons of heating/cooling capacity .................$235
Bored Geothermal Heat Exchanger Permit 10 to 50 tons of heating/cooling capacity ...........$475
Bored Geothermal Heat Exchanger Permit > 50 tons of heating/cooling capacity .................$700
If there are any questions, please contact me at 651-201-4589 or 800-383-9808.
KED:kad
Attachments
An equal opportunity employer
Minnesota Department of Health
Well Management Section
P.O. Box 64502
St. Paul, Minnesota 55164-0502
651-201-4600 or 800-383-9808
www.health.state.mn.us/divs/eh/wells
Instructions for Obtaining Permit to Install
Bored Geothermal Heat Exchanger
(Earth-Coupled Heat Loop)
Minnesota Statutes, chapter 103I authorizes the commissioner of health to issue permits for the
construction of bored geothermal heat exchangers. This includes any earth-coupled heating or
cooling device consisting of a closed loop piping system installed in a boring in the ground for
the purpose of transferring heat to or from the surrounding earth. Minnesota Rules, chapter 4725
"Wells and Borings" establishes the permit application requirements and the standards for the
construction, maintenance, and sealing of the bored geothermal heat exchanger.
Conditions of the permit approval include the following:
• A completed application form must be submitted, accompanied by the appropriate fee (the
fee is nonrefundable).
• The bored geothermal heat exchanger must be installed by a licensed well contractor or
licensed bored geothermal heat exchanger contractor.
• The construction, maintenance and sealing must be in compliance with Minnesota Rules,
chapter 4725.
• The owner agrees to allow inspection of the system during regular business hours by the
Minnesota Department of Health (MDH).
APPLICATION
A completed application must be submitted to the MDH, along with the appropriate fee and the
required documentation, which includes:
1. the name and license number of the well contractor and the certified representative;
2. the name and address of the owner of the property on which the bored geothermal heat
exchanger will be installed;
3. the township number, range number, section, and one quartile, and the property street
address, if assigned;
4. a plan diagram showing the location of the bored geothermal heat exchanger, property lines,
and structures on the property;
5. the number, diameter, and depth of all bore holes drilled to install the bored geothermal heat
exchanger piping;
6. the grout materials and grouting method;
7. the type of heat transfer fluid to be used;
8. the system operating pressure; and
9. the location of water-supply wells, utilities, and property lines.
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STANDARDS
In order to protect the quality of the groundwater resources of the state, the MDH will review
permit applications to determine compliance with the following standards:
1. Piping used must be a minimum 160 psi pressure-rated, SDR 11 high density, polyethylene
meeting ASTM Standard D3035-03a.
2. Connections to bored geothermal heat exchanger piping must use socket fusion or butt fusion
joining methods.
3. Piping must be pressure tested with air or potable water for 15 minutes at a pressure of
1.5 times the system operating pressure or 75 pounds per square inch, whichever is greater,
after installation in the bore hole.
4. The annular space between the bored geothermal heat exchanger piping and the bore hole
must be grouted according to the procedures in part 4725.3050, subpart 2. Rock portions
must be grouted with neat-cement or cement-sand grout. Portions of the hole in
unconsolidated formations must be grouted with bentonite grout, thermally enhanced
bentonite grout, neat-cement grout, or cement-sand grout.
5. Only food-grade or USP-grade propylene glycol must be used as heat transfer fluid. No other
materials or additives must be used except for potable water. A permanent sign must be
attached to the heat pump specifying that only approved heat transfer fluids must be used.
6. Water make-up line to the bored geothermal heat exchanger must be protected with a
backflow prevention device approved in part 4715.2110.
The owner of the bored geothermal heat exchanger must notify the commissioner of health
of heat loop fluid leakage or loss of pressure within 24 hours after the owner becomes
aware of the loss or leak.
The contractor must complete and return a postcard five days prior to beginning
construction or call Ms. Kara E. Dennis at 651-201-4589 at least 48 hours prior to
beginning construction. The postcard is mailed to the contractor with the approved permit.
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Minnesota Department of Health
Well Management Section
625 North Robert Street
P.O. Box 64502
St. Paul, Minnesota 55164-0502
651-201-4600 or 800-383-9808 Fax: 651-201-4599
www.health.state.mn.us/divs/eh/wells
(NOTE: Make check or money order payable to the Minnesota
Department of Health or by credit card using the attached Credit Card
Information form.)
Indicate Heating/Cooling Capacity:
< 10 Tons – $235
10 to 50 Tons – $475
> 50 Tons – $700
MDH USE ONLY
Date Received ________________________________
Amount Received _____________________________
Application No. _______________________________
□ $235 Bored Geothermal Heat Exchanger < 10 Tons
(272)
□ $475 Bored Geothermal Heat Exchanger 10 to 50 Tons (273)
□ $700 Bored Geothermal Heat Exchanger > 50 Tons
(274)
Schematic of Plumbing Design
Received ___________Approved ______________
Site Plan Showing Isolation Distances
Received ___________Approved ______________
Logs of the Holes, if Existing ____________________
Application for Permit to Install a Bored Geothermal Heat Exchange Device
(Earth-coupled heat loop) pursuant to Minnesota Statutes, chapter 103I and rules adopted thereunder
General Project Data to be completed by all applicants (please print or type all information provided).
Name of Certified Representative _________________________________________ Certified Representative No. _______________
Company Name __________________________________________________________ Company License No. _______________
Telephone No. (including area code) _____________________________________________________________________________
Street Address _______________________________________________________________________________________________
City, State, and ZIP Code ______________________________________________________________________________________
1. A. Legal Description of Bored Geothermal Heat Exchanger.
County
Township Name
Township
No.
Range
No.
Section
No.
Smallest
Quarter(s)
Quarter(s)
Quarter(s)
Largest
Quarter(s)
B. Bored Geothermal Heat Exchanger Location Site Address.
Street Address ______________________________________________________________________________________________
City, State, and ZIP Code _____________________________________________________________________________________
2. Bored Geothermal Heat Exchanger Owner Mailing Address.
Name _____________________________________________________________________________________________________
Street Address ______________________________________________________________________________________________
City, State, and ZIP Code _____________________________________________________________________________________
3. Property Owner Address (if different than the Bored Geothermal Heat Exchanger Owner Mailing Address).
Name _____________________________________________________________________________________________________
Street Address ______________________________________________________________________________________________
City, State, and ZIP Code _____________________________________________________________________________________
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4. Description of the Bored Geothermal Heat Exchanger – Construction Detail. Please supply the following
information where appropriate. If the bored geothermal heat exchangers are not yet constructed, write in the estimated
depths, sizes, and dates.
Number of Holes _________
Hole Depth(s) _______
Diameter of Piping(s) ________
Anticipated Depth to Bedrock ________
Piping Material:
High Density Polyethylene
Other ______________________________________________________
Grouting Material:
Neat Cement
Bentonite
Heat Transfer Fluid:
Cement Sand
USP-Grade or Food-Grade Propylene Glycol
Thermally Enhanced Bentonite
Other ______________
Other ________________________________________
5. Description of the Heat Pump Unit.
Name of Manufacturer __________________________________ Model No. ___________ Maximum Flow Rate _________ gpm
Name of Installer ____________________________________________________________________________________________
Pressure Rating – Maximum _____________ Minimum _____________ Installation Date (Actual or Proposed) _______________
6. Location of Bored Geothermal Heat Exchanger.
Indicate the location of the bored geothermal heat exchanger on an attached site plan showing isolation distances from water-supply
wells, power lines, gas lines, LP tanks, buildings, and property lines.
The site plan diagram must be attached.
7. Certified Representative Signature.
As a condition of this permit, I agree to construct this bored geothermal heat exchanger under the provisions of Minnesota Statutes,
chapter 103I and the rules adopted under it.
Signature ________________________________________________________
(Certified Representative)
Date_____________________________________
(mm/dd/yyyy)
8. Owner of Property Signature.
As a condition of this permit, I agree to operate and maintain this bored geothermal heat exchanger under the provisions of Minnesota
Statutes, chapter 103I and rules adopted thereunder and to allow inspection by the commissioner of health or his/her agent during
regular work hours.
Signature ________________________________________________________
(Owner of Property)
Date_____________________________________
(mm/dd/yyyy)
origs\Bored Geothermal Heat Exchanger Application and Memo.docx 1/22/2016R
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Well Management Section
625 North Robert Street
P.O. Box 64502
St. Paul, Minnesota 55164-0502
651-201-4591 or 800-369-1290 Fax: 651-201-4599
www.health.state.mn.us/divs/eh/wells
Credit Card Payment Information
Minnesota Unique Well No.
MN Well and Boring Sealing No.
H
Please complete and return this form if payment of fee(s) is by credit card. NOTE: If the notification form
already has the preprinted credit card information box DO NOT use this form.
Fee Type:
Elevator Boring Permit Application
License/Registration and/or Rig Registration
Maintenance Permit
Monitoring Well Permit Application
Variance Application
Bored Geothermal Heat Exchanger/Groundwater Thermal Exchange Permit Application
Well Notification
Well Sealing Notification
Credit Card Type:
Visa
MasterCard
Discover
Expiration Date: ________________________
Total Amount to be Charged: ________________________
Print Cardholder Name: ______________________________________________________________________
Credit Card Number: _________________________________________________________________________
3-Digit Security Code (Printed on backside of card.): ________________________
Authorized Signature: ________________________________________________________________________
Origs\Credit Card Single.docx
02/08/2016R