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, ;� -. C�t�z L i 1 �l � <br /> � F,� ��„�; � ��,�3_ 32z � <br /> Z r -�-� <br /> � � � « � s a F. �, . r,. r1�:.�.� <br /> MfNNES�TA DEPARTMENT C1F HEALTH �� `�� � <br /> , '.� WELL DlSCLOSURE CERTIFICATE ��'�Z� 3°� �`i�L� <br /> aes�xtwrp�cr�rairx PLEASE TYPE OR AR1NT ALL lNFORMATION <br /> 'Fill out r;epa�ate well informafion page if more than three welts are locefed on the properfy. <br /> WELL#1 � <br /> CQUNTY QUARTER(OR GOVERNMENT LOT) S�CTION NUMBER TOWNSHIP NUM9ER RANGE NUMBER <br /> Hennepin NW }�k- cJ� 4 117 23 <br /> WEL.L STATUS(Check only one box) YEAR WEL�WAS SEALED OR <br /> WELL IS; [] IN USE{1 j❑ NOT 1N USE(2)❑ SEALED BY LICENS�D WELL CONTRAGTOR{3) S�uirvGFtEGO�NUMa�R pF KNOWM <br /> (GaH MDH to verify sealing recard is on file.) <br /> ww�oF ucEr�v��t <br /> If ths well has been sealed by someone other than a li�ensed well coMrdctor or a COI�TFt,4CTOR <br /> licensed well sealing contractor,cheCk the well status as no!in use. <br /> WELL#2 <br /> COUNTY QUARTER(OR GOVERNMENT L0� SECTION NUMBcR TOWNSHIP NUMBER RANGE NUMBER <br /> WELL STATUS(Check only one 6ox) YEAR WELLWAS SF_Al.EO OR <br /> WELL IS� ❑ IN USE(1)�NOT(N USE(2j❑ SEALE�8Y LICENSED WELL CONTRAGTOR(3) SEALING RECORDNUMBER(IF KNOWN� <br /> (Call MDH to verify sealing record is on file.) <br /> NAM�OF UC�NSEO V+�ld. <br /> If the well has been sealed by someane other than a lic�nsed well contractor or a CwJrRnCTOR <br /> licensed well sealing contrach�r,check the weli sfatus as not in use. <br /> WEI.t,#3 <br /> COUNTY QUARTcR{OR GOVERNMENT L0� SECT(ON NUMBER TOWNSHIP NUMBER RANGE NUMBER <br /> WELt STATUS(Check only one hox) YEARUVELL WAS SEALED OR <br /> WE�L!S: ❑ IN USE(1)0 NOT 1N USE(�❑ SEAl.ED BY LICENSED WELL CONTRAGTOR(3) s�w��coRONunneEa pF ia,:owr�� <br /> (Cap MDH to vetify sealing record is on file.) �MEOFUCEN5EDINELL <br /> If the well has 6een sealed by someone other than a licensed we1!contractor or a ����'oR <br /> licensed wel!sealing contractor,check the well status as not in use. <br /> SKETCH MAP-Sketch the loca6on ot the well(s)and include estimated distancee from roads,streets,and buildings. <br /> IF MORE THAN ONE WELL ON PROPERTY,USE THE WElL LOCATION hiUMBER QBOVE TO 1DENTIFY <br /> F1�CW WELL. The locat;on of the wefl{s}must be provided. I(H►e location of a well is not known,have the welf <br /> iocated 6y a per�on qualified to lncate we!!s,such as a licensed well contractor. <br /> �1C�r�h, '�u�-h , £,�S r � �.� Sr �v QV1� �qV�.S'Z. <br /> x �� <br /> � <br /> � � � <br /> � <br /> .S <br /> trfocmation providad on this form is classified ae public(ntormailon under Minnesota Statutes, Chapter 13. <br /> To request this document in another format call(651)215-0811 or TOD(65t)215-0707 or greater Minnesote through M;nnesota <br /> Relay Service a,1-80G-627-3529 and ack for{651)295-0811.V;si;our web site at www.heallh.state.mn.usldlvsJehiwells/disdosuresl <br /> HE-0'l1E7�J9 <br /> tp�taaoaas 7/02R <br /> � � �G Bb�9 �ON ��dbb�l 900Z �r.�� ���r <br />