Abstract Over a three years period, an aquifer thermal energy storage system was monitored in combination with a heat pump for heating and cooling of the ventilation air in a Belgian hospital. The installation was one of the first and largest ground source heat pump systems in Belgium. Groundwater flows and temperatures were monitored as well as the energy flows of the heat pumps and the energy demand of the building. The resulting energy balance of the building showed that the primary energy consumption of the heat pump system is 71% lower in comparison with a reference installation based on common gas-fired boilers and water cooling machines. This corresponds to a CO2-reduction of 1280 ton over the whole measuring period. The overall seasonal performance factor (SPF) for heating was 5.9 while the ATES system delivered cooling at an efficiency factor of 26.1. Furthermore, the economic analysis showed an annual cost reduction of k€ 54 as compared to the reference installation, resulting in a simple payback time of 8.4 years, excluding subsidies.