Any senior groundwater right holder who believes that his water right has been impaired may notify the department of such impairment and request the assistance of the department to protect the availability of water to his qualifying withdrawal facilities. Such notification and request for assistance must be in writing and must contain the following information:

(1) Name, address and signature of the senior water right holder;

(2) Description of the water right, including the water right number if one exists; the quantities of water permitted and the quantities of water historically withdrawn; the priority date of the water right; the location of the withdrawal facilities; a description of the withdrawal facilities including well depth, casing, pump size and depth and historic water levels, and any recent changes made to the withdrawal facilities or the use of such facilities, especially in relation to WAC 173-150-030(8); the name of the water well contractor and a copy of the water well report of the construction of the withdrawal facilities, if available;

(3) Description of the alleged impairment of the senior water right, the date of the beginning of impairment, the degree of impairment and any steps taken by the senior water right holder to alleviate the impairment;

(4) Location and description of the junior water withdrawal facilities together with the name of the user thereof, if known, which in the opinion of the senior water right holder are the cause of the impairment;

(5) Any other pertinent information which may reasonably be required by the department.