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' � M � K N E : a r� MINNESOTA DEPARTMENT OF HEALTH <br /> � WELL DISCLOSURE CERTIFICATE Indicate Total Number of <br /> PLEASE TYPE OR PRINT ALL/NFORMATION wells on Property <br /> DEYItiNEMlo�HEdlfH <br /> Fill out a separate well information page if more than two wells are located on the property. <br /> E. WELL LOCATION LEGAL DESCRIPTION <br /> WELL#1 -If the property legal description has more than one section,township,or range number;quarter(or government lot); <br /> or lot or block number;provide specific legal description information regarding the physical location of this well. <br /> County Section No. Township No. Range No. Quarter(or Government Lot) <br /> Henne in i <br /> Lot No. Block No. Addition Name Outlot Tract MN Unique Well No.or Sealing <br /> Record No. <br /> WELL STATUS(Check only one box) �� Date of Well Construction or <br /> WELL IS: �n Use(1) ❑ Not in Use(2) ❑ Sealed by Licensed Well Contractor(3)' Sealing <br /> �Call MDH to verify sealing recard is on file <br /> Name of Licensed Well Contractor <br /> If the well has been sealed by someone other than a licensed well contractor or a licensed well sealing <br /> contractor,check the well status as not in use. Also see"IMPORTANT NOTE"on page 1. <br /> If well is not in use,is there an MDH variance for this well? If the well is not in use,is there an MOH maintenance permit <br /> ❑ Yes ❑ No for this well? ❑ Yes ❑ No <br /> If yes,provide the variance tracking number(TN) If yes,provide the permit number <br /> WELL#2-If the property legal description has more than one section,township,or range number;quaRer(or govemment lot); <br /> or lot or block number,provide specific legal description information regarding the physical location of this weil. <br /> County Section No. Township No. �I Range No. I Quarter(or Govemment Lot) <br /> i <br /> Lot No. Block No. Addition Name Outlot Tract MN Unique Well No.or Sealing <br /> Record No. <br /> WELL STATUS(Check only one box) Date of Well Construction or <br /> WELL IS: ❑ In Use(1) �Not in Use(2) ❑ Seaied by Licensed Well Contractor(3)` Sealing <br /> 'Call MDH to verify sealing record is on file <br /> Name of Licensed Well Contractor <br /> If the well has been sealed by someone other than a licensed well contractor or a licensed well sealing <br /> contractor,check the well status as not in�se. Also see"IMPORTANT NOTE"on page 1. <br /> If well is not in use,is there an MDH variance for this well? If the well is not in use,is there an MDH maintenance permit <br /> ❑ Yes ❑ No for this we117 ❑ Yes ❑ No <br /> �f yes,provide the variance tracking number(TN) If yes,provide the permit number <br /> SKETCH MAP-Sketch the location of the well(s)and include estimated distances from roads, streets,and buildings. If more <br /> than one well on property,use the well location number above to identify each well. The location of the well(s)must be <br /> provided. If the location of a well is not known,have the well located by a person qualified to locate wells,such as a licensed <br /> well contractor. <br /> ��' ��,�,�,C�. <br /> �� <br /> Information provided on this form is classified as public information under Minnesota Statutes,Chapter 13. <br /> To request this document in another format,call 651/201-4600. Deaf and hard-of-hearing: TTY 651/201-5797. <br /> Visit the MDH Well Management Section,Well Disclosure Program web site at: www.health.state.mn.us/divs(ehlwell/disclosures <br /> HE-01387-11 IC#140-0385 origs\well disclosure certificate-instructions 07/08R <br />