application form geoexchange system certification - Canadian ...

APPLICATION FORMGEOEXCHANGE SYSTEMCERTIFICATION

INSTRUCTIONS TO COMPLETE THIS CERTIFICATION FORM1) All spaces must be completed with information or “N/A” if not applicable2) A copy of this document must be kept by the customer and one copy sent to the Canadian GeoExchange Coalition (CGC). Completeone form for each operating heat pump system. Where one heat pump system (at one given civic address) uses more thanone heat pump unit, applicants must provide serial numbers and any particular details in section IV, subsection seven, “Other SystemSpecifications.”3) Incomplete forms will be returned to applicants for completion, before approval can be granted. Please therefore fully completethis form.4) Instructions for each section are generally provided at the beginning of each section, next to section titles.5) If normal CGC or CSA protocols are not followed in the completion of this form, the professional responsible for the work shouldprovide a separate page describing the deviation, the reasoning for it, and requesting a specific exception for specific reasons.Please note that CGC will not and does not guarantee that any accommodation will be made in certifying systems which do notfollow to the letter of C-448-02.6) This Certification Form may be used to fit the needs of financial assistance programs developed by utilities, municipality, provincialand federal governments and other stakeholders. Please be as accurate as possible in providing information, as the approval offinancial assistance to customers may depend on the quality and accuracy of the information provided herein.7) Please ensure that Section II is completed and signed by all CGC-Accredited individuals involved in construction of this system.8) If you are in Manitoba, Manitoba Hydro’s Start-Up Verification Report may be substituted for Section IV of this form.9) Once this form is complete, all information will be kept confidential by CGC except for any authorized used per Section VII of thisform, or as ordered by a Court of Law having jurisdiction in Canada.In addition to this completed questionnaire, the request for certification must also include the following documents:1) A clearly legible copy of the CGC GeoExchange Drilling Report, or a water well record or well construction report as required byprovincial regulations.2) A clearly legible copy of the site survey worksheet completed with final details and dimensions of the complete system. Pleaseconsult CSA 448, Annex B for a template.3) A clearly legible copy of the heat loss calculations for this system.4) A copy of the municipal permit for work and renovationCertification fee:125 $ (including taxes)A numbered certificate (sticker) to be fixed visibly on your system along with a 8 1/2 x 11 paper certificate will be mailed directly to thecustomer. Depending on the province and the financial assistance program you are applying for, you will need to either produce the certificatenumber or a copy of the paper certificate.Why pay a Certification fee?Certification confirms that the System installed at the address listed in Section I-B has been designed and installed in full compliance withthe C448 Series-02 Design and Installation of Earth Energy Systems standard. In addition, part of the certification process requiresthat the installation team review your system materials and operating procedures with you (the customer), and provide documentationwhich can be of essential help in the unlikely event of a system problem. Finally, certification means that design and installation professionalshave passed the industry standard training courses in the technology, conduct their business affairs honourably in general, andalready have a positive track record of high quality installations. The Certification fee helps CGC manage this quality process.Customer / system ownerPlease return the completed formaccompanied with supportingdocuments and payment to:By mail only:By fax: 1-866-643-1375Canadian GeoExchange Coalition1030 Cherrier St, Suite 405Montréal (Québec) H2L 1H9

Application Form — CGC System CertificationCGC-CERT-E-04/2008I-A. SYSTEM OWNER IDENTIFICATIONSystem Owner’s Name:Address of installation:Address (line 2):City: Province/State: Postal/Zip Code:Telephone:Fax:E-mail:I-B. OTHER SYSTEM OWNER INFORMATION (if applicable)ECOENERGY Retrofit FILE NUMBER ( ’D’ NUMBER ) :OTHER INCENTIVE PROGRAMME : FILE NUMBER :II. CGC ACCREDITED PROFESSIONALS INVOLVED IN THE DESIGN, DRILLING AND INSTALLATION OF THE GEOEXCHANGE SYSTEM1) Accredited Installer:CGC Accreditation Number:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)2) Accredited Designer:CGC Accreditation Number:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)3) Qualified Drilling Firm /Other CGC Accredited Prof.:CGC Accreditation Number:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)Page 1 / 8

III.OTHER PROFESSIONALS INVOLVED IN THE DESIGN, DRILLING AND INSTALLATION OF THE GEOEXCHANGE SYSTEMCGC-CERT-E-04/2008If relevant, please list all other professionals involved in the installation of this geoexchange system. Depending on the province or municipality, this may includegeneral contractors, subcontractors, drillers, electricians, plumbers, and/or other construction professionals.Please use another sheet if you need to provide more names.1) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)2) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)3) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)4) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)5) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)6) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)7) Name of professional:Signature:Title & Role on this Project: (e.g. General Contractor, Sub, etc.)Page 2 / 8

IV. CSA 448 DESIGN AND INSTALLATION COMPLIANCE & COMMISSIONING REPORTCGC-CERT-E-04/20081. General Information on the Building and the Geoexchange System UseNew construction: Existing building: Type of building (bungalow, cottage, etc,):If existing building:Type of heating system before retrofit:Type of cooling system before retrofit:Age of the building:Insulation work completed:Size of the building in ft 2 or m 2 (excluding basement):Geoexchange system used for:Living area space heating & coolingDomestic water heatingPool water heatingSaunaHeating & cooling of other adjacent buildingsOtherDate construction began:Date construction ended:Total costs of geoexchangeinstallation & desing:2. Specific System InformationType of distribution system : Forced-air HydronicA copy of load calculations was given to the customerHeat pump make:Heating capacity:Coefficient of performance—heating (nominal):Design heat load (building) :Design cooling load (building) :Model / Serial No. :Cooling capacity:Seasonal energy efficiency rating:Check off appropriate entering water temperature (Refer to CAN/CSA-C13256) Heating: 0 o C 10 o C Cooling: 25 o C 15 o C3. Loop InformationOpen-LoopFlow:Imp. Gallon / hour (data from driller) orUS gallon / minHeat transfer fluid :Concentration (%):Type of soil at depths:VerticalNumber of boreholes :Depth of boreholes :Flow :US gallon / minClosed-LoopTypes of soil :HorizontalDepth of loop / heat exchanger:Length of heat exchanger:Flow:US gallon / minPipes diameter :Pond LoopDepth of loop / heat exchanger:Flow:US gallon / minLength of heat exchanger:Pipes diameter :Page 3 / 8

4. Full Load Operating ConditionsCGC-CERT-E-04/2008Turn off the desuperheater and emergency heating unit if applicable. For commissioning and measurement of operating conditions, please operate to full capacity (compressor and EMC at100 %) and all zones open. Do not forget to turn the desuperheater and the emergency heating unit back on if applicable.Air (water for water to water)Water temperaturePressure (water)HEATINGIn Out Delta°F °F ∆T=°F°F °F ∆T=°FPSI PSI ∆P= PSICOOLINGIn Out Delta°F °F ∆T=°F°F °F ∆T=°FPSI PSI ∆P= PSICompressorVentilatorampsampsampsamps5. System Components1. Auxiliary heating 4. Pumping kit7. Flow reader2. Desuperheater3. Anti vibrationOther5. Filter6. Thermostat, model8. Pete’s plug9. Humidification6. Emergency Heating Unit (for air distribution systems only)AirIn°FOut°FDelta∆T= °FVoltage (measured)VPCM =kW x 34001,1 x ∆T°F=Nominal capacity :kWNominal voltage :V7. Other System Specifications (for example, if there are more than one heat pump, include all the HP unit model & serial numbers here).Page 4 / 8

V. As-Built-Book and Commissioning Checklist—To be completed by the CGC Accredited ProfessionalCGC-CERT-E-04/2008CGC-Certified Systems must demonstrate that the design and installation process fully conforms with C-448, CGC training, and industry best practices. Therefore, the following documentationis required to complete the application. Full documentation of installation and design can help protect installation professionals and suppliers from future liability issues, as well as allowfor faster diagnosis of any future problems.A) As-Built-Book — The following documentation shall to be provided to the system owner. Please check the following blanks to confirm documentation delivery. CGC stronglyrecommends that installing professionals keep a copy of as-built material to protect themselves from liability issues._____ Initial CSA Site Survey sheet, and copies of any relevant notes taken in course of adjustment to this document._____ Evidence of proper system labelling. Checklist properly attached to HP unit, labels on supply and fluid return lines, and properly labelled loop charging valves, with datesclearly marked_____ Final Site Report, and any relevant notes taken in the course of design and installation_____ Materials Safety Data Sheets for heat transfer fluids used in application (optional but recommended)_____ Any manufacturer start-up sheets and documentation, manuals for heat pumps and piping materials, and any other owner’s guides (photocopies are acceptable)_____ Manufacturer warranties and guarantees for equipment used in installation_____ Installer guarantees to customer & installer service centre contact information_____ A copy of the completed CGC Verification of System Delivery Form from Section VII of this document, signed by customer and one (1) witness_____ Photographs of any work involving ground penetration, and photographs of the completed installation, in electronic or hard copy, with dates clearly marked. (This element isoptional but highly recommended)Please refer to your training materials, FAQ documentation, instructors, and / or your copy of C-448 for all forms and materials, before calling CGC staff on this matter.B) Commissioning Checklist: Both the customer and the CGC accredited professional / Qualified firm representative providing the workmanship guarantee shall initial each taskas they are completeted, in the spaces provided belowClientCGC Professional_______ _______ Current Service company contact information has been provided to the customer_______ _______ Copy of CSA 448 Design and Installation Compliance & Commissioning Report (Section IV of this document) has been provided to the owner_______ _______ Supply and return valves are marked clearly and appropriately_______ _______ Final dimensioned site plan has been provided to owner (Including dimensions / location of all piping, diameters, depths and lengths of loops,septic systems, water inlet lines, lot lines, telephone, hydro, gas, etc.)_______ _______ Label affixed at loop charging valve showing antifreeze type, concentration, contractor information_______ _______ Owner is informed of the terms and conditions of the manufacturer warranty_______ _______ Owner is informed of any possible effects on supply water well related to water quality and quantity, etc (if an open-loop system)_______ _______ Any boreholes grouted and sealed in accordance with CGC instruction on best groundwater protection practises, and allapplicable regulations and CSA standards._______ _______ All interior pipes are insulated to prevent sweating_______ _______ P/T plugs are installed as close as possible to the entering and return water ports on the cabinet_______ _______ Air filter has been installed (if a water-air system)_______ _______ Trapped condensate drain has been installed in accordance with applicable plumbing codes_______ _______ Flushing and purging ports are installed_______ _______ System has been reversed flushed to remove air_______ _______ Tracer wire or equivalent has been installed on all buried horizontal piping for ease of location_______ _______ System has been pressure tested per CSA requirements_______ _______ A copy of the as-built book including a CGC Borehole well construction report as required by the province was given to the customerPage 5 / 8

CGC-CERT-E-04/2008VI. AFFIDAVIT — To be completed and signed by the company / firm representative providing workmanship guarantee on the systemSolemn declaration of professional in construction industryI, undersigned,soussigné,[name[position]for[Company]having its principal place of business located at(hereinafter referred to as the “Company”), hereby solemnly declare that:1. I am the ________________________________[position] for the Company and I have held this position since ____________[year].2. Because of my functions and position within the Company, I am generally aware of its business activities and possess full authority torepresent it herein by subscribing to this solemn declaration. I am particularly aware of the circumstances surrounding it and I haveaccess to all relevant documents and information.3. To the best of my and the Company’s knowledge, all the information contained in this application is true and accurate.4. Although membership in the CGC is not mandatory to apply for Certification, all the work related to the system within this form(“System”) has been conducted in accordance with and meets the highest ethical standards in geoexchange work, including all criteriaof CSA C-448.5. The Company understands, accepts and recognizes that Certification is only granted to systems which at a minimum meet current CSAstandards for design and installation (or accepted government deviations / utility program requirements), and meet current Canadianstandards for safety and performance.6. The Company understands, accepts and recognizes that unless and until an industry recognized standard is adopted, Certificationdoes not cover direct expansion or standing column well systems.7. The System installed at the address listed in Section I-B has been designed and installed in full compliance with the C448 Series-02Design and Installation of Earth Energy Systems standard.8. The Company understands, accepts and recognizes that a false declaration may result in the loss of its accreditation / qualificationstatus with the CGC.9. The Company understands, accepts and recognizes that Certification can be immediately revoked at any time, at the sole discretion ofthe CGC, and without any formality, if the Company fails to provide or to continue providing evidence that the System is designed,installed and is performing to standards, as per instructions in this certification form.Signed in ____________________________________________[city, province], this _____ day of the month of_______________ [mois], 200___.Signature:Please print nameWitness:Please print namePage 6 / 8

VII. VERIFICATION OF SYSTEM DELIVERY — To be completed and signed by the customerCGC-CERT-E-04/2008Client’s Understanding and Approval of CertificationI, undersigned,[name]domiciled and residing at[address]hereby solemnly declare that:1. I am applying to the Canadian GeoExchange Coalition (“CGC”) to have the System certified. I am the owner of the System.2. I understand that one of the criteria for CGC certification (“Certification”) is that I verify that the System has been delivered in good orderalong with the “As-built” book and a Commissioning Checklist. In this regard, I hereby confirm that a member of the installation team hasreviewed the Commissioning Checklist with me (found in section V of the CGC Certified System application), and has provided me with allthe information listed in the As-built book. I am satisfied with the working order and my understanding of the System.3. I understand and agree that Certification or CGC Accreditation is not a substitute for my own due diligence regarding the drilling, designand installation of the System, including but not limited to contractor review and oversight, reference verification and credit verification.4. I understand and agree that CGC’s program is not in any way a substitute for the moral, contractual and legal responsibilities of the workersinvolved with the project.5. As an express and essential condition for entering into this quality programme agreement, I hereby agree and understand that the CGCshall not in any way be legally or contractually responsible or liable for any claims, demands, suits and costs, including attorneys fees,arising out of drilling, design and installation of the System or any direct or indirect damage or prejudice caused by it.6. I authorize the CGC to share all required information with the programs from which I am seeking financial or other assistance or support.7. I authorize CGC personnel or designated representatives of the CGC to inspect my System in order to ensure its conformity with codes,standards and other regulations in my municipality or province.8. To the best of my understanding this system has been installed and designed properly in accordance with all applicable standards, lawsand regulations.9. The geoexchange system named in this application is providing heating and cooling satisfactorily, and though I reserve all legal rights regardingfuture problems, I am at this time satisfied with the work and workmanship conducted, including the professional ethics and allefforts made by the professionals named in this application.Signed at _________________________________________[city, province], this ______ day of the month of _______________ [month], 200___.Signature:Please print nameWitness:Please print namePage 7 / 8

CGC GeoExchangeDrilling ReportDRILLING FIRM, NAME & ADDRESS:WORK LOCATION:MUNICIPALITYPROVINCEBOREHOLE NO.DATE OF DRILLING:OPERATOR NAME:EQUIPMENT (drill rig)1030, rue Cherrier StreetBureau 405Montreal, Qc., H2L 1H9fax 514 807 8221D E P T HOverburden : mWeathered rock: mCompetent rock: mTOTAL DEPTH: mMATERIAL DESCRIPTIONSTEEL TUBING (CASING)OVERBURDEN DEPTH:mCASING DEPTH (LENGTH):mDIAMETER (INT).:cmDIAMETER (EXT).:cmGEO PIPES (HDPE, CSA C448 compliant)POLYETHYLENE PIPES SDR:DIAMETER (INT).:inchFLOW (Q)Q END DRILLING:STATIC LEVEL:m 3 /hmHORIZONTAL SECTIONDEPTH OF:Excavation:mPolye. pipes:mD E P T H(m)CUTG E O L O G YLITHOLOGYDESCRIPTIONWater (fracture)FLOW(m 3 /h)DEPTH(m)D R I L L AND GEOTHERMAL W O R KGEOTHERMAL HOLE BUILDINGMETHODDIAMETERADVANCE SPEED(m/h)10305070STEEL TUBING(CAISSING)10POLYETHYLENE PIPES2030MIXBENTONITESILICA SAND:PoundPoundCONDUCTIVITY:btu40 hr*ft*°f5060NOT TO SCALEDrill holeType:Diameter:708090100150Length:M200Page 8 / 8