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Well Disclosure Certificate

  1. Person filing deed must include a $50 fee payable to the county recorder.

  2. I certify that the information provided on this certificate is accurate and complete to the best of my knowledge.

  3. For fulfillment of a contract for deed, the buyer or person authorized to act on behalf of the buyer, must sign a Well Disclosure Certificate if there is a well on the property.

    In the absence of a seller's signature, the buyer, or person authorized to act on behalf of the buyer may sign this Well Disclosure Certificate. No signature is required by the buyer if the seller has signed above.

    Based on disclosure information provided to me by the seller or other available information, I certify that the information on this certificate is accurate and complete to the best of my knowledge.

  4. Minnesota Department of Health (MDH) will follow-up with the property buyer regarding any wells disclosed as not in use. If a well is not in use, the property owner must either return the well to use, have the well sealed by a licensed well contractor, or obtain an annual maintenance permit from MDH for $175. A copy of this Well Disclosure Certificate should be provided to the property buyer at the time of closing.

  5. If the property legal description has more than one section, township, or range number; quarter (or government lot); or lot or block number; provide specific legal description information regarding the physical location of this well.

  6. Well is:

  7. *Call MDH to verify sealing record is on file.

    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. Also see "Important Note" above.

  8. If well is not in use, is there an MDH variance for this well?

  9. If the well is not in use, is there an MDH maintenance permit for this well?

  10. If the property legal description has more than on section, township, or range number; quarter (or government lot); or lot or block number; provide specific legal description information regarding the physical location of this well.

  11. Well is:

  12. *Call MDH to verify sealing record is on file.

    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. Also see "Important Note" above.

  13. If well is not in use, is there an MDH variance for this well?

  14. If the well is not in use, is there an MDH maintenance permit for this well?

  15. Sketch the location of the well(s) and include estimated distances from roads, streets, and buildings. If there is more than one well on the property, use the well location number above to identify each well. The location of the well(s) must be 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 well contractor.

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  17. This field is not part of the form submission.