Free GX-02, Application For Certification - Colorado

Form No.: GX-02 9/2008 TYPE OR PRINT IN BLACK INK

Division of Water Resources, 1313 Sherman Street, Room 818 Denver, CO 80203 Phone 303-866-3581 Fax 303-866-3589

Office Use:

APPLICATION FOR CERTIFICATION FOR CLOSED-LOOP GEOTHERMAL WELL CONSTRUCTION
Type of Closed-loop Geoexchange systems to be constructed? Applicant Information Full Name:________________________________________________________________________________ Mailing Address:____________________________________________________________________________ City, State, Zip:_____________________________________________________________________________ Phone Number:________________________________ Fax Number:_________________________________

Business Name:___________________________________________________________________________ Business Address:___________________________________________________________________________ City, State, Zip:_____________________________________________________________________________ Phone Number: _______________________________ Fax Number:_________________________________

Bond/Insurance (provide copy) ________________________________________________________________ State the approximate number of closed-loop geothermal systems you have constructed: _________. Number of years/months of closed-loop geothermal well construction experience? __________. Are you familiar with the general near-surface geology and hydrogeology of the areas that you intend to construct closed-loop geothermal systems in? ______________

For Vertical Closed-loop Systems
Equipment Information Describe the type of drilling rig/equipment to be used to construct the boreholes for the closed-loop geothermal systems:__________________________________________________________________________ Describe the type of grouting equipment to be used to grout the boreholes for the closed-loop geothermal systems:___________________________________________________________________________________

Signature: ___________________________________________________________ Date: _______________________________________________________________