2. Well Disclosure Requirements
   Well Disclosure Requirements (PDF)

   Please read over the Well Disclosure Requirements before filling out the Well Disclosure Certificate form.
4. Person filing deed must include a $50 fee payable to the county recorder.
6. A. Property Location Legal Description
8. Attach a legal description of property.
10. County
11. Section Number
12. Township Number
14. Range Number
15. Quarter (or Government Lot)
16. Lot Number(s)
18. Block Number
19. Addition Name
20. Outlot
22. Tract
24. Property Street Address
26. City
27. Zip Code
29. Property ID Number / Parcel Number (optional)
33. B. Property Buyer Mailing Address After Closing
35. First Name
36. Middle Initial
37. Last Name
39. Company Name (if applicable)
41. Mailing Address
43. City
44. State
45. Zip Code
47. Phone
49. Provide Name of Seller
53. C. Certification by Seller
    I certify that the information provided on this certificate is accurate and complete to the best of my knowledge.
55. Signature of Seller or Designated Representative of Seller
56. Date
    Date
60. D. Certification by Buyer
    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.
62. Signature of Buyer or Designated Representative of Buyer
63. Date
    Date
65. Important Note:
    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.
69. E. Well Location Legal Description
71. Well Number 1
    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.
73. County
74. Section Number
75. Township Number
77. Range Number
78. Quarter (or Government Lot)
79. Lot Number
81. Block Number
82. Addition Name
83. Outlot
85. Tract
86. MN Unique Well Number or Sealing Record Number
88. Well Status
90. Well is:

    1. In Use
    2. Not In Use
    3. Sealed by Licensed Well Contractor*
91. Date of Well Construction or Sealing
    Date of Well Construction or Sealing
92. Name of Licensed Well Contractor
94. *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.
96. If well is not in use, is there an MDH variance for this well?

    1. Yes
    2. No
97. If yes, provide the variance tracking number (TN)
99. If the well is not in use, is there an MDH maintenance permit for this well?

    1. Yes
    2. No
100. If yes, please provide the permit number:
102. Well Number 2
     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.
104. County
105. Section Number
106. Township Number
108. Range Number
109. Quarter (or Government Lot)
110. Lot Number
112. Block Number
113. Addition Name
114. Outlot
116. Tract
117. MN Unique Well Number or Sealing Record Number
119. Well Status
121. Well is:

     1. In Use
     2. Not in Use
     3. Sealed by Licensed Well Contractor*
122. Date of Well Construction or Sealing
     Date of Well Construction or Sealing
123. Name of Licensed Well Contractor
125. *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.
127. If well is not in use, is there an MDH variance for this well?

     1. Yes
     2. No
128. If yes, provide the variance tracking number (TN):
130. If the well is not in use, is there an MDH maintenance permit for this well?

     1. Yes
     2. No
131. If yes, please provide the permit number:
133. Sketch Map
     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.
135. Upload Sketch
Leave This Blank:


137. 1. Receive an email copy of this form.
138. Email address

     This field is not part of the form submission.

139. Submit

* indicates a required field