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DISCLOSURE STATEMENT:WELL This form approved by the Minnesota Association of REALTORS' which disclaims any liability arising out of use or misuse of this form. P2017 Minnesota Association of REALTORS'.Edina,MN 1. Date 1ot/5 J 2(4/ - 2. Page 1 of pages: THE REQUIRED MAP 3. IS ATTACHED HERE AND MADE A PART OF THIS 4. DISCLOSURE 5. Minnesota Statute 1031.235 requires that,before signing an agreement to sell or transfer real property,Seller must 6. disclose information in writing to Buyer about the status and location of all known wells on the property.This requirement 7. is satisfied by delivering to Buyer either a statement by Seller that Seller does not know of any wells on the property, 8. or a disclosure statement indicating the legal description and county,and a map showing the location of each well.In 9. the disclosure statement Seller must indicate,for each well,whether the well is in use,not in use or sealed. 10. Unless Buyer and Seller agree to the contrary in writing,before the closing of the sale,a Seller who fails to disclose 11. the existence or known status of a well at the time of sale,and knew or had reason to know of the existence or known 12. status of the well,is liable to Buyer for costs relating to sealing of the well and reasonable attorneys'fees for collection 13. of costs from Seller,if the action is commenced within six years after the date Buyer closed the purchase of the real 14. property where the well is located. 15. Legal requirements exist relating to various aspects of location and status of wells. Buyer is advised to 16. contact the local unit(s) of government, state agency, or qualified professional which regulates wells for further 17. information about these issues.For additional information on wells,please visit the Minnesota Department of Health's 18. website at www.health.state.mn.us. 19. Instructions for completion of this form are on page three(3). 20. PROPERTY DESCRIPTION:Street Address:___ 3 l-ld CrI i E A v E (1`-) _ 21. ELK oelz MIN 553. 0 cueg Li��- (L'tY) (Zip) (Count?,; 22, LEGAL DESCRIPTION: Lor 1 ' ju jiT0!i; S uAQ{V f to ., P tIli g ACc:.'O/ik(. 23. I o .. OE SLA 7 b" IA 2t= t= $H.E ke.u 0 r" (2 iii 3 24. 25. WELL DISCLOSURE STATEMENT:(Check appropriate boxes.) 26. Seller certifies that the following wells are located on the above-described real property. 27. MN Unique Well Year of Well IN USE NOT IN SHARED SEALED 28. Well No. Depth Const. Type USE 29. Well 1 30. Well 2 ; 31. V.te11 3 32. Is this property served by a well not located on the property? fl YOs El No 33. If"Yes."please explain: 34. 35. NOTE: See definition of terms"IN USE,""NOT IN USE,"and"SEALED"on lines 102-113.If a well is not in use,it 36. must be sealed by a licensed well contractor or a well owner must obtain a maintenance permit from 37. the Minnesota Department of Health and pay an annual maintenance fee.Maintenance permits are not 38. transferable.if a well is operable and properly maintained,a maintenance permit is not required. 39. If the well is,"Shared"• 40. (1) How many properties or residences does the shared well serve? 41. (2) Who manages the shared well?-- 42. (3) Is there a maintenance agreement for the shared well? Yes r� well? ("Yes �_6 No 43. If"Yes,'what is the annual maintenance fee`? MN-DS:W-t d'' 7, instc: