The Elk River rises in Avery County, North Carolina just south of the small community of Elk Park, North Carolina on U.S. Highway 19E. in Pisgah National Forest. For most of the river's course, it runs in a deep gorge. Just before the Elk River crosses into Tennessee it flows over "Big Falls" (also called "Elk Falls"), a locally-known attraction which is approximately a 40 foot (12 m) drop. It then flows down a narrow, relatively steep valley to the tiny community of Elk Mills, which is named for a former water-powered mill built on this river at this point by early white settlers. Between the state line and Elk Mills, it flows over Twisting Falls, a drop of approximately 30 feet (nine m). At this point, it is bridged by U.S. Highway 321. Shortly below this point, it waters become slack as part of an embayment of Watuaga Lake, a sizable reservoir of the Watauga Dam Project of the Tennessee Valley Authority. This project has flooded the actual site of the original confluence of the Elk and Watauga Rivers.