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Authentisign ID:16706484-ACC8-47DF-BA07-E7DEFF933E7F <br /> Coldwell Banker Burnet WELL DISCLOSURE STATEMENT <br /> 42. Page 2 <br /> 43. Property located al 4550 Wolverton Place Orono 55359 <br /> 44. OTHER WELL INFORMATION: • <br /> 45. Date well water last tested for contaminants: Test results attached? ❑Yes ❑No <br /> 46. Comments: <br /> 47, <br /> 48. <br /> 49. <br /> 50. <br /> 51. <br /> 52, <br /> 53. Contaminated Well:Is there a well on the property containing contaminated water? Eyes ❑No <br /> 64. SEALED WELL INFORMATION:For each well designated as sealed above,complete this section. <br /> 55. When was the well sealed? <br /> 58. Who sealed the well? <br /> 57. Was a Sealed Well Report filed with the Minnesota Department of Health? ❑Yes CI No <br /> 58, MAP:Complete the attached MAP showing the location of each well on the real properly, <br /> 59. This disclosure Is not a warranty of any kind by Seller(s)or any licensee(s)representing or assisting any part(/les)In <br /> 60. this transaction and Is not a substitute for any Inspections or warranties the party(ies)may wish to obtain. <br /> 61. CERTIFICATION BY SELLER:I certify that the Information provided above Is accurate and complete to the <br /> 62. besl3 28E'/21 nigclSk9.e <br /> 63. 2/1612013 12:21:26 PM— 02/16/2013 <br /> (Dote) (5et'.ee or De-Mgna;t3 Rey,esenhlare) (Dale) <br /> 64. BUYER'S ACKNOWLEDGEMENT: <br /> 65. _ Nd 1) L l (( f <br /> ('�) IOste) uye() (Date) <br /> 66. ORIGINAL COPY TO LISTING BROKER;COPIES TO SELLER,BUYER,SELLING BROKER. <br /> MtQ•WOS•1(8/07) <br /> V.SSFom.s''Nev12008 <br />