While the geomorphic consequences of Pleistocene megafloods have been known for some time, it has been only in the past 2 decades that hydrogeologists and glaciologists alike have begun to appreciate the important impact that ice sheet–aquifer interactions have had in controlling subsurface flow patterns, recharge rates, and the distribution of fresh water in confined aquifer systems across North America. In this paper, we document the numerous lines of geochemical, isotopic, and geomechanical evidence of ice sheet hydrogeology across North America. We also review the mechanical, thermal, and hydrologic processes that control subsurface fluid migration beneath ice sheets. Finite element models of subsurface fluid flow, permafrost formation, and ice sheet loading are presented to investigate the coupled nature of transport processes during glaciation/deglaciation. These indicate that recharge rates as high as 10 times modern values occurred as the Laurentide Ice Sheet overran the margins of sedimentary basins. The effects of ice sheet loading and permafrost formation result in complex transient flow patterns within aquifers and confining units alike. Using geochemical and environmental isotopic data, we estimate that the volume of glacial meltwater emplaced at the margins of sedimentary basins overrun by the Laurentide Ice Sheet totals about 3.7 × 10⁴ km³, which is about 0.2% of the volume of the Laurentide Ice Sheet. Subglacial infiltration estimates based on continental-scale hydrologic models are even higher (5–10% of meltwater generated). These studies in sum call into question the widely held notion that groundwater flow patterns within confined aquifer systems are controlled primarily by the water table configuration during the Pleistocene. Rather, groundwater flow patterns were likely much more complex and transient in nature than has previously been thought. Because Pleistocene recharge rates are believed to be highly variable, these studies have profound implications for water resource managers charged with determining sustainable pumping rates from confined aquifers that host ice sheet meltwater.