Per- and polyfluoroalkyl substances (PFAS) are persistent environmental contaminants, yet most studies evaluate wastewater and surface waters as separate environmental compartments, limiting understanding of PFAS transport across connected aquatic systems. This study investigated PFAS occurrence, mixture composition, and cumulative contamination across municipal wastewater treatment plant (WWTP) effluent and hydrologically connected surface waters within a single watershed in southwestern Illinois, USA. The concentrations of 55 targeted PFAS in WWTP and surface water samples were determined by U.S. EPA Methods 533, 537, and 1633 coupled with solid-phase extraction and high-performance liquid chromatography–tandem mass spectrometry (HPLC–MS/MS). Mixture-based statistical approaches, including Bray–Curtis dissimilarity analysis, non-metric multidimensional scaling (NMDS), and permutational multivariate analysis of variance (PERMANOVA), were used to evaluate compositional similarity among sampling matrices. PFAS were detected in every sample, with 20 compounds identified overall. WWTP effluent exhibited the highest cumulative PFAS burden (median ΣPFAS = 49.6 ng/L) and greatest chemical diversity, with 18 compounds detected compared with 9–10 compounds in individual surface-water systems (median ΣPFAS = 9.75–18.2 ng/L). Perfluorobutanoic acid (PFBA), perfluorobutane sulfonic acid (PFBS), perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorohexanoic acid (PFHxA), and perfluoropentanoic acid (PFPeA) were consistently detected across sampling matrices, whereas perfluorodecanoic acid (PFDA), perfluoropropane sulfonic acid (PFPrS), perfluoro-4-ethylcyclohexane sulfonic acid (PFECHS), perfluorononanoic acid (PFNA), perfluoropentane sulfonic acid (PFPeS), 6:2 fluorotelomer sulfonate (6:2 FTS), 2h-perfluoro-2-decenoic acid (FOUEA), and N-methyl perfluorooctane sulfonamidoacetic acid (N-MeFOSAA) were detected exclusively in WWTP effluent. PFAS chemical diversity was strongly correlated with cumulative PFAS concentrations (Spearman ρ = 0.94, p < 0.001). This is the first study to document PFAS concentrations in WWTP effluent and Richland Creek in southern Illinois. PFAS mixture composition differed significantly among water sources, with water source explaining 53.8% of compositional variation (PERMANOVA, p < 0.001); more broadly, the distinction between WWTP effluent and surface water explained 34.1% of compositional variation (p < 0.001). These findings demonstrate distinct but compositionally related PFAS profiles across municipal WWTP effluent and hydrologically connected surface waters. The results also highlight the value of mixture-based approaches for characterizing PFAS occurrence, cumulative contamination, and compositional patterns across interconnected aquatic systems. Such approaches provide additional information beyond individual-compound assessments and may support wastewater management, environmental monitoring, and future PFAS risk assessment.