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0 <br />C] <br />WATER SUPPLY WELL LOCATION SURVEY FORM <br />SECOR Internahonal <br />3017 Kilgore Road, Suite 100 <br />Rancho Cordova Cahfomla <br />(916) 861-0400 <br />May 10, 2004 <br />Well Survey Site Address <br />Yes No <br />0 � A water well is present on the property <br />0 DomesticlDnnking water well <br />0 Agricultural/Landscape water well <br />Unknown <br />Yes No <br />Q ff Is the well being used? <br />If known, please provide well construction details <br />Date installed <br />Depth of well <br />Casing Type, <br />Casing diameter <br />Screen interval <br />Survey completed by <br />Name 4 Oe <br />Signature i� <br />Date o v <br />