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I <br /> I 0 <br /> WATER SUPPLY WELL LOCATION SURVEY FORM <br /> F' POZO DE AQUA POSICION/ FORMA DE ENTREVISTA <br /> SECOR International <br /> 3475 Rest Shaw Ave, Suite 104 <br /> Fresno, California <br /> (559)271-2650 <br /> October/Octubre 2004 <br />' Well Survey Site Address/Pozo de Sato de Entrevista <br /> Street/Calle ezfl'Awaq <br />' City/Cuidad <br /> !6�' CJnL <br /> State/Estado,Zip Code/CSdigo Postal D <br /> Yes/St No <br /> A water well is present on the property?/Un pozo de ague esti presente sobre la <br />' caracteristica(proptedad) '? <br /> Domestic/Drmlang water well/Pozo de agua Dom6stico/potable <br />' 7 Agricultural/Landscape water well/Pozo de Agua agricola/paisaje <br /> Unknown/Desconocido <br />' <br /> Ye#S1 No <br /> [;D L_j Is the well being used?/LPozo el es usado7 <br /> If known,please provide well construction details/Si conocido,por favor suministre pozo detalles de <br />' construcm6n <br />' Date mstalled/Fecha instalada <br /> Depth of well/Prof indidad de Pozo <br /> Casing Typw Tipo de Cubierta <br />' Casing diameter/Dtimetro de cubierta <br /> Screen intsrval/Intervalo de pantalla <br />' Survey completed by/Revisi6n completada por - - <br /> Name/Nornbre <br /> 1 Signature/Firma <br />' Q--- <br /> Datefflecha -Zilu <br /> 1 <br />