HomeMy WebLinkAboutAbandoned Well CertificateMINNESOTA DEPARTMENT OF HEALTH
WELL DISCLOSURE CERTIFICATE
PLEASE TYPE ALL INFORMATION
%. PROPERTY SELLER INFORMATION
Progress Land Company, Inc.
Seller's last name , , 1
Date of closing the sale Total number of wells , .1.
M M D D Y Y
PROPERTY DESCRIPTION
Attach a legal description of property in addition to the applicable property
information requested below.
leg
6 3;03 . r fi T gin m e I .- -i .--I .
House number Street name Type Direction
Prtgr Ldke 55-172
City Zip code
If applicable.
Earniana HiI] � R' tr LdA'fi' 1 1 , ' ' 'S'
Addition name Block number Lot number
PROPERTY BUYER INFORMATION
L LL
First name MI Last name
Company name if applicable
A . Address
. .
Address
I �
City State Zip code
Phone number
CERTIFIGJITION BY SELLER
1 oeryly that he Mir m Lion fti' "dad on this cerwicats b accurate and complete to the best of my Ynowtedge.
Sig•atme of sm1 or ciesignaTed Fepressmative of Selbf Date
CERTIFICATION BY BUYER
In the absence of a seller's signature, the buyer, or person authorized te act on behalf of the Guyer may sign this wail carbilowe. No
signature Is required by the buyer it the seller her signed abo,e.
Based on d,sclosufe information provided to me by the gelter os other aveiiable information, I cartity that ibe information provided above
is accurate and complete W Use best of my knowtedge.
Signature of Buyer or Designated Rapreaantatiw of Buyer
F. CONTRACT FOR DEED PROPERTY TRANSFERS DEED ONLY
The buyer, or person auhorzed to act on behalf of the buyer, must dpn a Walt Disclosure Gertilloate for all warrant' dead$ given N
fulfillment of a contract for deed. n onto are no known web an dre properly. stock to box below.
0 1 early that I know Of tto wags to the property described twain.
Signat_:a of Buyer of Designated Papnsamadve of Buyer fib
MINNESOTA DEPARTMENT OF HEALTH
WELL DISCLOSURE CERTIFICATE Cof�
WELL INFORMATION
Fill out a separate form for each well located on the property.
A. WELL LOCATION
County Snntt
Pri nr, T nkc y$W I u u IA ,26 1,19 , 27� y
Township name Ouaner Ouaner Ouener Owner Section m. Township W. Mnpe W.
e. WELL USE INFORMATION
1. , Unique well number (if known). 2. ,161, , Well depth (feet).
3. Unknown , Year of construction. 4. , w, Well type pee immucuonsl•
5. , Permit number if current maintenance permit exists.
6. Well is: ❑ in use 1,I ❑ not in use R1 ® sealed by licensed well contractor pl
,1993` , Year well was sealed.
C. SKETCH MAP
Please use the space below to sketch the location of the well. Include distances fro¢
fixed reference points such as streets and buildings.
*See Attached Plat Maps
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