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r � MINNESOTA DEPARTMENT OF HEALTH . WELL DISCLOSURE CERTIFICATE PLEASE TYPE OR PRINT ALL INFORMATION *-Fill out a separatewell information page if more than three wells are located on the property. WELL #1 COUNTY QUARTER(OR GOVERNMENT LOT) I SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER )kAllki WELL STATUS (Check only one box) YEAR WELL WAS SEALED(i WN) WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑SEALED BY LICENSED WELL CONTRACTOR(3) NAME OF LICENSED WELL CONTRACTOR If the well has been sealed by someone other than a licensed well contractor or a licensed well sealing contractor,check the well status as not In use. WELL #2 " COUNTY QUARTER(OR GOVERNMENT LOT) SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER WELL STATUS (Check only one box) YEAR WELL WAS SEALED(IF KNOWN) WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑SEALED BY LICENSED WELL CONTRACTOR(3) _ NAME OF LICENSED WELL CONTRACTOR IIf the well has been sealed by someone other than a licensed well contractor or a licensed well sealing contractor,check the well status as not in use. WELL #3 COUNTY QUARTER(OR GOVERNMENT LOT) SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER WELL STATUS (Check only one box) YEAR WELL WAS SEALED(Ir KpOWN) WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑SEALED BY LICENSED WELL CONTRACTOR(3) NAME OF LICENSED WELL CONTRACTOR It the well has been sealed by someone other than a licensed well contractor or a licensed well sealing contractor,check the well status as not In use. SKETCH MAP—Sketch the location of theweli(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 K�✓I d e ti/ft 1 w� LL f o LL) Information provided on this form is classified as pub0c Information under Minnesota Statutes,Chapter 13. To request this document In another format call(612)215-0700 or TDD (612)215-0707,or greater Minnesota through Minnesota Relay Service at 1-800-627-3529 and ask for(612)215-0811.