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I <br /> WATER SUPPLY WELL LOCATION SURVEY FORM <br /> POZO DE AQUA POSICION/ FORMA DE ENTREVISTA <br />' SECOR International <br /> 3475 West Shaw Ave, Suite 104 <br />' Fresno, California <br /> (559)271-2650 <br />' October/Octubre 2004 <br />' Well Survey Site Address/Pozo de Sitio de Entrevista <br /> Street/Calle 2-S533 rd, H-o1w.qt4 <br />' City/Cuidad p <br /> State/Estado,Zip Code/C6digo Postal (,�5•� <br /> Ye Si No <br /> A water well is present on the property?/Un pozo de agua esti presente sobre la <br />' caracteristica(propiedad)9 <br /> Domestic/Dnnlang water well/Pozo de agua Dom6stico/potable <br />' Agricultural/Landscape water well/Pozo de Agua agricola/paisaje <br />' Yes/Si No <br /> Is the well being used?/LPozo el es usado? <br />' If known,please provide well construction detads/Sx oonocido,por favor sumuixstre pozo detalles de <br /> construcciGn. <br />' Date mstalled/Fecha instalada <br /> Depth of well/Profundtdad de Pozo <br /> Casing Type/Tipo de Cubierta <br />' Casing diameter/Difimetro de cubierta <br /> Screen mtervalAntervalo de pantalla <br />' Survey completed by/Revisibn completada por <br /> Name/Nombre S hame Furgal of SECOR for homeowner/business owner <br /> Signatureffl mia- <br />' Date/Fecha Cb <br />