2000-11-14 MNDH Well Info0
MINNESOTA DEPARTMENT OF HEALTH
WELL INFORMATION
PLEASE TYPE OR PRINT ALL INFORMATION
* Fill out a separate well information page if more than three wells are located on the property.
WELL LOCATION #1
COUNTY
QUARTER
SECTION NUMBER
TOWNSHIP NUMBER
RANGE NUMBER
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WELL STATUS
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YEAR WELL WAS SEALED (IF KNOWN)
WELL IS: ❑ IN USE (1)
�M NOT IN USE (2) ❑ SEALED BY LICENSED WELL CONTRACTOR (3)
WELL LOCATION #2
COUNTY
QUARTER
SECTION NUMBER
I TOWNSHIP NUMBER
I RANGE NUMBER
WELL STATUS
YEAR WELL WAS SEALED (IF KNOWN)
WELL IS: ❑IN USE (1) ❑ NOT IN USE (2) ❑ SEALED BY LICENSED WELL CONTRACTOR (3)
WELL LOCATION #3
COUNTY
QUARTER
SECTION NUMBER
I TOWNSHIP NUMBER
RANGE NUMBER
WELL STATUS
YEAR WELL WAS SEALED (IF KNOWN)
WELL IS: ❑IN USE (1) ❑ NOT IN USE (2) ❑ SEALED BY LICENSED WELL CONTRACTOR (3)
SKETCH MAP - Sketch the location of the well(s) and include estimated distances from roads, streets, and buildings.
IF MORE THAN ONE WELL ON PROPERTY, USE THE WELL LOCATION NUMBER ABOVE TO IDENTIFY EACH WELL.
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Information provided on this form is classified as public information under Minnesota Statutes, Chapter 13.
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MINNESOTA DEPARTMENT OF HEALTH
jChj WELL DISCLOSURE CERTIFICATE
PLEASE TYPE OR PRINT ALL INFORMATION
Person filing deed must attach $10 fee payable to county recorder.
A. PROPERTY DESCRIPTION
Attach a legal description of property if the property does not have a lot number, block number,
and addition name.
COUNTY
NUMBER
BLOCK NUMBER
ADDITION NAME
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ZLOT
STREET ADRESS
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CITY
STATE
ZIP CODE
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B. PROPERTY BUYER MAILING ADDRESS AFTER CLOSING
FIRST NAME
MIDDLE INITIAL
LAST NAME
COMPANY NAME (IF APPLICABLE)
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ADDEES
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ADDRESS
CITY / LL
STATE
ZIP CODE
TELEPHONE NUMBER
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C. CERTIFICATION BY SELLER
I certify that the information provided on this certificate is accurate and complete to the best of my knowledge.
Signature of Seller or Designated Representative of Seller Date
D. CERTIFICATION BY BUYER
The buyer or person authorized to act on behalf of the buyer, must sign a Well Disclosure Certificate for all deeds given in fulfillment of
a contract for deed if there is a well on the property.
In the absence of a seller's signature, the buyer, or person authorized to act on behalf of the buyer may sign this well certificate.
No signature is required by the buyer if the seller has signed above.
Based on disclosure information provided to me by the seller or other available information, I certify that the information on this certificate
is accurate and complete to the best of my knowledge.
Signature of Buyer or Designated Representative of Buyer Date
(OVER)