The Little Sandy rises in southern Elliott County and flows generally north-northeastwardly in a meandering course through Elliott, Carter and Greenup counties, through the towns of Sandy Hook and Grayson.
At its mouth, the Little Sandy River's mean annual discharge is 840.51 cubic feet per second (23.801 m3/s).
[3] A U.S. Army Corps of Engineers dam in Carter County causes the river to widen as Grayson Lake in southern Carter and northern Elliott Counties.
Grayson Lake State Park is located along this impoundment.
The East Fork Little Sandy River, 48.3 miles (77.7 km) long,[1] joins the main stream in Greenup County.