Xikuangshan (XKS) is the world's largest antimony mining region, and its exploitation for hundreds of years has also resulted in serious soil erosion, fragile ecology, contaminated water, and shortage water. Through systematic and scientific collection samples from the rivers in XKS, the Nemerow index (NI), modified heavy metal pollution index (m-HPI), ecological risk index, and health risk indexeswere used to evaluate and analyze the water quality, pollution levels and risks of heavy metals (Sb, As, Mn, Pb, Zn, Hg, Cd) to ecology and humans in XKS. The results showed that the average concentrations of TN, TP, Sb, As and Hg in surface water were 0.48 mg/L (0–4.34 mg/L), 2.58 mg/L (0–4.34 mg/L), 1.05 mg/L (0.0009–5.33 mg/L), 1.06 mg/L (BDL–19.60 mg/L) and 0.00084 mg/L (LDBL–0.0036 mg/L), respectively, exceeding the limits of the Chinese surface water quality standards. Based on the m-HPI method, only 8.57% of the sampling points are classified as the worst water quality. However, according to the NI method, about 7.14% and 87.16% of the sampling points in the study area are moderately and severely polluted, respectively. The results of heavy metal pollution based on the NI evaluation is were more serious than that on the m-HPI method. The values of ecological risk assessment varied from 22.69 to 7351.20, revealed that heavy metals pose a very serious risk to the surface water ecosystem at more than 50% of the sampling sites, and Sb and As are the main pollutants, followed by Hg. The total non-carcinogenic risk index (TCR) for adults and children were 47.70 and 90.10 respectively, Sb and As is the main non-carcinogenic risk factor. For adults and children, the average carcinogenic risk (CR) of As was 6.49 × 10^–3 and 1.05 × 10^–2, respectively, and exceeded the threshold of 1 × 10–⁴, indicating a high carcinogenic risk.